ppo 2016 evidence of coverage - memorial …...tagalog: mayroon kaming libreng serbisyo sa...

Memorial Hermann Advantage PPO

2016 Evidence of Coverage

29041_MHHI_MA_EOC_Cover_PPO_EN_PROD.indd 1 9/1/15 5:33 PM

16EE1-PDZ-MAPPO

Y0110_MLI_0715 CMS Accepted 7/15/2015

Multi-Language Insert

Multi-language Interpreter Services

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January 1 – December 31, 2016

Evidence of Coverage:

Your Medicare Health Benefits and Services and Prescription Drug Coverage as aMember of Memorial Hermann Advantage PPOThis booklet gives you the details about your Medicare health care and prescription drug coverage from January1 – December 31, 2016. It explains how to get coverage for the health care services and prescription drugs youneed. This is an important legal document. Please keep it in a safe place.

This plan, Memorial Hermann Advantage PPO, is offered by Memorial Hermann Health Insurance Company.(When this Evidence of Coverage says “we,” “us,” or “our,” it means Memorial Hermann Health InsuranceCompany.When it says “plan” or “our plan,” it means Memorial Hermann Advantage PPO.)

Memorial Hermann Advantage PPO is a health plan with a Medicare contract. Enrollment in Memorial HermannAdvantage PPO depends on contract renewal.

Memorial HermannHealth Solutions, Inc. is the parent company ofMemorial HermannHealth Insurance Companyand Memorial Hermann Health Plan, Inc., both of which are Medicare Advantage organizations.

This information is available for free in other languages. Please contact our Customer Service number at (844)550-6896 for additional information. (TTY/TDD users should call 711). Hours are 8 a.m. to 8 p.m. seven days aweek.Customer Service also has free language interpreter services available for non-English speakers.

Esta información es disponible, gratis, en otros idiomas. Favor de contactar el departamento del servicio al clienteal (844) 550-6896 para obtener más información. (Usuarios de TTY/TDD debe llamar a 711). Horas de servicioson desde las 8 de la mañana hasta las 8 de la noche, 7 días por semana. También ofrecemos gratis traduccionesde idiomas, disponibles a los que no hablan inglés.

We must provide information in a way that works for you (in languages other than English, in Braille, in largeprint, or other alternate formats, etc.).

Benefits, formulary, pharmacy network, premium, deductible, and/or copayments/coinsurance may change onJanuary 1, 2017.

Y0110_POST_PPOMAPD16_CMS Accepted 9/10/2015 Form CMS 10260-ANOC/EOC(Approved 03/2014)

16EE1-PDZ-MAPPOOMB Approval 0938-1051

2016 Evidence of Coverage

Table of contents

This list of chapters and page numbers is your starting point. For more help in finding informationyou need, go to the first page of a chapter. You will find a detailed list of topics at the beginningof each chapter.

Chapter 1. Getting started as a member ................................................................4

Explains what it means to be in a Medicare health plan and how to use thisbooklet. Tells about materials we will send you, your plan premium, your planmembership card, and keeping your membership record up to date.

Chapter 2. Important phone numbers and resources ........................................ 17

Tells you how to get in touch with our plan (Memorial Hermann AdvantagePPO) and with other organizations including Medicare, the State HealthInsurance Assistance Program (SHIP), the Quality Improvement Organization,Social Security, Medicaid (the state health insurance program for people withlow incomes), programs that help people pay for their prescription drugs, andthe Railroad Retirement Board.

Chapter 3. Using the plan’s coverage for your medical services ...................... 33

Explains important things you need to know about getting your medical careas a member of our plan. Topics include using the providers in the plan’snetwork and how to get care when you have an emergency.

Chapter 4. Medical Benefits Chart (what is covered and what you pay) .......... 48

Gives the details about which types of medical care are covered and not coveredfor you as a member of our plan. Explains how much you will pay as yourshare of the cost for your covered medical care.

Chapter 5. Using the plan’s coverage for your Part D prescription drugs ....... 88

Explains rules you need to follow when you get your Part D drugs. Tells howto use the plan’s List of Covered Drugs (Formulary) to find out which drugsare covered. Tells which kinds of drugs are not covered. Explains severalkinds of restrictions that apply to coverage for certain drugs. Explains whereto get your prescriptions filled. Tells about the plan’s programs for drug safetyand managing medications.

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 1Table of Contents

Chapter 6. What you pay for your Part D prescription drugs .......................... 109

Tells about the four (4) stages of drug coverage (Deductible Stage, InitialCoverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) andhow these stages affect what you pay for your drugs. Explains the five (5)cost-sharing tiers for your Part D drugs and tells what you must pay for a drugin each cost-sharing tier. Tells about the late enrollment penalty.

Chapter 7. Asking us to pay our share of a bill you have received for coveredmedical services or drugs ................................................................130

Explains when and how to send a bill to us when you want to ask us to payyou back for our share of the cost for your covered services or drugs.

Chapter 8. Your rights and responsibilities .......................................................138

Explains the rights and responsibilities you have as a member of our plan.Tells what you can do if you think your rights are not being respected.

Chapter 9. What to do if you have a problem or complaint (coverage decisions,appeals, complaints) .........................................................................149

Tells you step-by-step what to do if you are having problems or concerns asa member of our plan.

1 Explains how to ask for coverage decisions and make appeals if youare having trouble getting the medical care or prescription drugs youthink are covered by our plan. This includes asking us to makeexceptions to the rules or extra restrictions on your coverage forprescription drugs, and asking us to keep covering hospital care andcertain types of medical services if you think your coverage is endingtoo soon.

1 Explains how to make complaints about quality of care, waiting times,customer service, and other concerns.

Chapter 10. Ending your membership in the plan .............................................. 200

Explains when and how you can end your membership in the plan. Explainssituations in which our plan is required to end your membership.

Chapter 11. Legal notices ......................................................................................209

Includes notices about governing law and about nondiscrimination.


Chapter 12. Definitions of important words ........................................................212

Explains key terms used in this booklet.


CHAPTER 1Getting started as a

member

Chapter 1. Getting started as a member

SECTION 1 Introduction ............................................................................................7

Section 1.1 You are enrolled in Memorial Hermann Advantage PPO, which is aMedicare PPO ................................................................................................... 7

Section 1.2 What is the Evidence of Coverage booklet about? ........................................... 7

Section 1.3 Legal information about the Evidence of Coverage ......................................... 7

SECTION 2 What makes you eligible to be a plan member? ................................. 8

Section 2.1 Your eligibility requirements ............................................................................ 8

Section 2.2 What are Medicare Part A and Medicare Part B? ............................................. 8

Section 2.3 Here is the plan service area for Memorial Hermann Advantage PPO ............ 8

SECTION 3 What other materials will you get from us? ......................................... 9

Section 3.1 Your plan membership card – Use it to get all covered care and prescriptiondrugs ................................................................................................................. 9

Section 3.2 The Provider Directory: Your guide to all providers in the plan’snetwork ............................................................................................................. 9

Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network ............ 10

Section 3.4 The plan’s List of Covered Drugs (Formulary) .............................................. 10

Section 3.5 The Part D Explanation of Benefits (the “Part D EOB”): Reports with asummary of payments made for your Part D prescription drugs .................... 11

SECTION 4 Your monthly premium for Memorial Hermann AdvantagePPO ........................................................................................................11

Section 4.1 How much is your plan premium? ................................................................. 11

Section 4.2 If you pay a Part D late enrollment penalty, there are several ways you canpay your penalty ............................................................................................. 13

Section 4.3 Can we change your monthly plan premium during the year? ....................... 14

SECTION 5 Please keep your plan membership record up to date .................... 14

Section 5.1 How to help make sure that we have accurate information about you ........... 14

SECTION 6 We protect the privacy of your personal health information ........... 15

Section 6.1 We make sure that your health information is protected ................................ 15

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 5Chapter 1. Getting started as a member

SECTION 7 How other insurance works with our plan ......................................... 15

Section 7.1 Which plan pays first when you have other insurance? ................................. 15


SECTION 1 Introduction

Section 1.1 You are enrolled in Memorial Hermann Advantage PPO, which is aMedicare PPO

You are covered by Medicare, and you have chosen to get your Medicare health care and yourprescription drug coverage through our plan, Memorial Hermann Advantage PPO.

There are different types ofMedicare health plans.Memorial HermannAdvantage PPO is aMedicareAdvantage PPO Plan (PPO stands for Preferred Provider Organization). Like all Medicare healthplans, this Medicare PPO is approved by Medicare and run by a private company.

Section 1.2 What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet tells you how to get yourMedicare medical care and prescriptiondrugs covered through our plan. This booklet explains your rights and responsibilities, what iscovered, and what you pay as a member of the plan.

The word “coverage” and “covered services” refers to the medical care and services and theprescription drugs available to you as a member of Memorial Hermann Advantage PPO.

It’s important for you to learn what the plan’s rules are and what services are available to you. Weencourage you to set aside some time to look through this Evidence of Coverage booklet.

If you are confused or concerned or just have a question, please contact our plan’s Customer Service(phone numbers are printed on the back cover of this booklet).

Section 1.3 Legal information about the Evidence of Coverage

It’s part of our contract with youThisEvidence of Coverage is part of our contract with you about howMemorial HermannAdvantagePPO covers your care. Other parts of this contract include your enrollment form, the List of CoveredDrugs (Formulary), and any notices you receive from us about changes to your coverage orconditions that affect your coverage. These notices are sometimes called “riders” or “amendments.”

The contract is in effect for months in which you are enrolled in Memorial Hermann AdvantagePPO between January 1, 2016 and December 31, 2016.

Each calendar year, Medicare allows us to make changes to the plans that we offer. This means wecan change the costs and benefits of Memorial Hermann Advantage PPO after December 31, 2016.We can also choose to stop offering the plan, or to offer it in a different service area, after December31, 2016.

Medicare must approve our plan each year


Medicare (the Centers for Medicare & Medicaid Services) must approve Memorial HermannAdvantage PPO each year. You can continue to get Medicare coverage as a member of our plan aslong as we choose to continue to offer the plan and Medicare renews its approval of the plan.

SECTION 2 What makes you eligible to be a plan member?

Section 2.1 Your eligibility requirements

You are eligible for membership in our plan as long as:

1 You have both Medicare Part A and Medicare Part B (section 2.2 tells you about MedicarePart A and Medicare Part B)

1 -- and -- you live in our geographic service area (section 2.3 below describes our servicearea)

1 -- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions, suchas if you develop ESRD when you are already a member of a plan that we offer, or you werea member of a different plan that was terminated.

Section 2.2 What are Medicare Part A and Medicare Part B?

When you first signed up for Medicare, you received information about what services are coveredunder Medicare Part A and Medicare Part B. Remember:

1 Medicare Part A generally helps cover services provided by hospitals (for inpatient services,skilled nursing facilities, or home health agencies.

1 Medicare Part B is for most other medical services (such as physician’s services and otheroutpatient services) and certain items (such as durable medical equipment and supplies).

Section 2.3 Here is the plan service area for Memorial HermannAdvantage PPO

Although Medicare is a Federal program, Memorial Hermann Advantage PPO is available only toindividuals who live in our plan service area. To remain a member of our plan, you must continueto reside in the plan service area. The service area is described below

Our service area includes these counties in Texas: Harris, Fort Bend and Montgomery.

If you plan to move out of the service area, please contact Customer Service (phone numbers areprinted on the back cover of this booklet). When you move, you will have a Special EnrollmentPeriod that will allow you to switch to Original Medicare or enroll in a Medicare health or drugplan that is available in your new location.


It is also important that you call Social Security if you move or change your mailing address. Youcan find phone numbers and contact information for Social Security in Chapter 2, Section 5.

SECTION 3 What other materials will you get from us?

Section 3.1 Your plan membership card – Use it to get all covered care andprescription drugs

While you are a member of our plan, you must use your membership card for our plan wheneveryou get any services covered by this plan and for prescription drugs you get at network pharmacies.Here’s a sample membership card to show you what yours will look like:

As long as you are a member of our plan you must not use your red, white, and blue Medicarecard to get covered medical services (with the exception of routine clinical research studies andhospice services). Keep your red, white, and blue Medicare card in a safe place in case you needit later.

Here’s why this is so important: If you get covered services using your red, white, and blueMedicare card instead of using your Memorial Hermann Advantage PPO membership card whileyou are a plan member, you may have to pay the full cost yourself.

If your plan membership card is damaged, lost, or stolen, call Customer Service right away and wewill send you a new card. (Phone numbers for Customer Service are printed on the back cover ofthis booklet.)

Section 3.2 The Provider Directory: Your guide to all providers in the plan’snetwork

The Provider Directory lists our network providers and durable medical equipment suppliers.

What are “network providers”?Network providers are the doctors and other health care professionals, medical groups, durablemedical equipment suppliers, hospitals, and other health care facilities that have an agreement with


us to accept our payment and any plan cost-sharing as payment in full. We have arranged for theseproviders to deliver covered services to members in our plan.

Why do you need to know which providers are part of our network?As a member of our plan, you can choose to receive care from out-of-network providers. Our planwill cover services from either in-network or out-of-network providers, as long as the services arecovered benefits and medically necessary. However, if you use an out-of-network provider, yourshare of the costs for your covered services may be higher. See Chapter 3 (Using the plan’s coveragefor your medical services) for more specific information.

If you don’t have your copy of the Provider Directory, you can request a copy from CustomerService (phone numbers are printed on the back cover of this booklet). You may ask CustomerService for more information about our network providers, including their qualifications. You canalso see the Provider Directory at healthplan.memorialhermann.org/medicare, or download it fromthis website. Both Customer Service and the website can give you the most up-to-date informationabout changes in our network providers.

Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network

What are “network pharmacies”?

Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for ourplan members.

Why do you need to know about network pharmacies?

You can use the Pharmacy Directory to find the network pharmacy you want to use. An updatedPharmacy Directory is located on our website at healthplan.memorialhermann.org/medicare. Youmay also call Customer Service for updated provider information or to ask us to mail you a PharmacyDirectory. Please review the 2015 Pharmacy Directory to see which pharmacies are in ournetwork.

If you don’t have the Pharmacy Directory, you can get a copy from Customer Service (phonenumbers are printed on the back cover of this booklet). At any time, you can call Customer Serviceto get up-to-date information about changes in the pharmacy network. You can also find thisinformation on our website at healthplan.memorialhermann.org/medicare.

Section 3.4 The plan’s List of Covered Drugs (Formulary)

The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tellswhich Part D prescription drugs are covered under the Part D benefit included inMemorial HermannAdvantage PPO. The drugs on this list are selected by the plan with the help of a team of doctorsand pharmacists. The list must meet requirements set by Medicare. Medicare has approved theMemorial Hermann Advantage PPO Drug List.

The Drug List also tells you if there are any rules that restrict coverage for your drugs.


We will send you a copy of the Drug List. The Drug List we send to you includes information forthe covered drugs that are most commonly used by our members. However, we cover additionaldrugs that are not included in the printed Drug List. If one of your drugs is not listed in the DrugList, you should visit our website or contact Customer Service to find out if we cover it. To get themost complete and current information about which drugs are covered, you can visit the plan’swebsite (healthplan.memorialhermann.org/medicare) or call Customer Service (phone numbers areprinted on the back cover of this booklet).

Section 3.5 The Part D Explanation of Benefits (the “Part D EOB”): Reports witha summary of payments made for your Part D prescription drugs

When you use your Part D prescription drug benefits, we will send you a summary report to helpyou understand and keep track of payments for your Part D prescription drugs. This summary reportis called the Part D Explanation of Benefits (or the “Part D EOB”).

The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, havespent on your Part D prescription drugs and the total amount we have paid for each of your Part Dprescription drugs during the month. Chapter 6 (What you pay for your Part D prescription drugs)gives more information about the Part D Explanation of Benefits and how it can help you keeptrack of your drug coverage.

A Part D Explanation of Benefits summary is also available upon request. To get a copy, pleasecontact Customer Service (phone numbers are printed on the back cover of this booklet).

SECTION 4 Your monthly premium for Memorial Hermann AdvantagePPO

Section 4.1 How much is your plan premium?

You do not pay a separate monthly plan premium for Memorial Hermann Advantage PPO. Youmust continue to pay your Medicare Part B premium (unless your Part B premium is paid for youby Medicaid or another third party).

In some situations, your plan premium could be more

In some situations, your plan premium could be more than the amount listed above in Section 4.1.These situations are described below.

1 If you signed up for extra benefits, also called “optional supplemental benefits”, then youpay an additional premium each month for these extra benefits. If you have any questionsabout your plan premiums, please call Customer Service (phone numbers are printed on theback cover of this booklet).

1 There is a $49.00 monthly premium for the Memorial Hermann Advantage (PPO) Pack.


1 Some members are required to pay a late enrollment penalty because they did not join aMedicare drug plan when they first became eligible or because they had a continuous periodof 63 days or more when they didn’t have “creditable” prescription drugcoverage. (“Creditable” means the drug coverage is at least as good as Medicare’s standarddrug coverage.) For these members, the late enrollment penalty is added to the plan’s monthlypremium. Their premium amount will be the monthly plan premium plus the amount of theirlate enrollment penalty.

4 If you are required to pay the late enrollment penalty, the amount of your penalty dependson how long you waited before you enrolled in drug coverage or how many months youwere without drug coverage after you became eligible. Chapter 6, Section 10 explains thelate enrollment penalty.

4 If you have a late enrollment penalty and do not pay it, you could be disenrolled from theplan.

Many members are required to pay other Medicare premiumsMany members are required to pay other Medicare premiums. As explained in Section 2 above, inorder to be eligible for our plan, you must be entitled to Medicare Part A and enrolled in MedicarePart B. For that reason, some plan members (those who aren’t eligible for premium-free Part A)pay a premium for Medicare Part A. And most plan members pay a premium for Medicare Part B.You must continue paying your Medicare premiums to remain a member of the plan.

Some people pay an extra amount for Part D because of their yearly income, this is known IncomeRelated Monthly Adjustment Amounts, also known as IRMAA. If your income is greater than$85,000 for an individual (or married individuals filing separately) or greater than $170,000 formarried couples, you must pay an extra amount directly to the government (not the Medicareplan) for your Medicare Part D coverage.

1 If you are required to pay the extra amount and you do not pay it, you will be disenrolledfrom the plan and lose prescription drug coverage.

1 If you have to pay an extra amount, Social Security, not your Medicare plan, will send youa letter telling you what that extra amount will be.

1 For more information about Part D premiums based on income, go to Chapter 6, Section 11of this booklet. You can also visit http://www.medicare.gov on the Web or call1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users shouldcall 1-877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY/TDD usersshould call 1-800-325-0778.

Your copy ofMedicare & You 2016 gives information about the Medicare premiums in the sectioncalled “2016 Medicare Costs.” This explains how the Medicare Part B and Part D premiums differfor people with different incomes. Everyone with Medicare receives a copy of Medicare & Youeach year in the fall. Those new to Medicare receive it within a month after first signing up. Youcan also download a copy of Medicare & You 2016 from the Medicare website (http://


www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users call 1-877-486-2048.

Section 4.2 If you pay a Part D late enrollment penalty, there are several waysyou can pay your penalty

If you pay a Part D late enrollment penalty, there are three (3) ways you can pay the penalty.

If you decide to change the way you pay your late enrollment penalty, it can take up to three monthsfor your new payment method to take effect. While we are processing your request for a newpayment method, you are responsible for making sure that your late enrollment penalty is paid ontime.

Option 1: You can pay by checkIf you elect Direct Bill option, your late enrollment penalty notice will be mailed to you on the 6thday of each calendar month. Your late enrollment penalty payment will be due, via personal check,cashier’s check or money order, upon receipt. Please remit payments payable to:

Memorial Hermann Health Insurance CompanyLockbox 301662Dallas, TX 75303-1662

Please include your payment along with the statement coupon and your Member ID written on thecheck, cashier’s check, or money order.

Option 2: You can pay automatic withdrawal from your checking or saving accountIf you elect to pay via Automatic Bank Withdrawal from your checking or savings account, yourlate enrollment penalty payment will be automatically deducted from your checking or savings onor around the 5th day of each month. You may contact Customer Service and request a ChangeNotice Form, which will include specific instructions, to set up Automatic Bank Withdrawal.

Option 3: You can have the late enrollment penalty taken out of your monthly SocialSecurity checkYou can have the late enrollment penalty taken out of your monthly Social Security check. ContactCustomer Service for more information on how to pay your penalty this way. We will be happyto help you set this up. (Phone numbers for Customer Service are printed on the back cover of thisbooklet.)

What to do if you are having trouble paying your late enrollment penaltyYour late enrollment penalty is due in our office by the first day of each month.

If you are having trouble paying your late enrollment penalty on time, please contact CustomerService to see if we can direct you to programs that will help with your penalty. (Phone numbersfor Customer Service are printed on the back cover of this booklet.)


Section 4.3 Can we change your monthly plan premium during the year?

No.We are not allowed to begin charging a monthly plan premium during the year. If the monthlyplan premium changes for next year we will tell you in September and the change will take effecton January 1.

However, in some cases, youmay need to start paying or may be able to stop paying a late enrollmentpenalty. (The late enrollment penalty may apply if you had a continuous period of 63 days or morewhen you didn’t have “creditable” prescription drug coverage.) This could happen if you becomeeligible for the “Extra Help” program or if you lose your eligibility for the “Extra Help” programduring the year:

1 If you currently pay the late enrollment penalty and become eligible for “Extra Help” duringthe year, you would be able to stop paying your penalty.

1 If you ever lose “Extra Help”, you must maintain your Part D coverage or you could besubject to a late enrollment penalty.

You can find out more about the “Extra Help” program in Chapter 2, Section 7.

SECTION 5 Please keep your plan membership record up to date

Section 5.1 How to help make sure that we have accurate information aboutyou

Your membership record has information from your enrollment form, including your address andtelephone number. It shows your specific plan coverage including your Primary Care Provider.

The doctors, hospitals, pharmacists, and other providers in the plan’s network need to have correctinformation about you. These network providers use your membership record to know whatservices and drugs are covered and the cost-sharing amounts for you. Because of this, it is veryimportant that you help us keep your information up to date.

Let us know about these changes:1 Changes to your name, your address, or your phone number.

1 Changes in any other health insurance coverage you have (such as from your employer, yourspouse’s employer, workers’ compensation, or Medicaid).

1 If you have any liability claims, such as claims from an automobile accident.

1 If you have been admitted to a nursing home.

1 If you receive care in an out-of-area or out-of-network hospital or emergency room.

1 If your designated responsible party (such as a caregiver) changes.

1 If you are participating in a clinical research study.


If any of this information changes, please let us know by calling Customer Service (phone numbersare printed on the back cover of this booklet).

It is also important to contact Social Security if you move or change your mailing address. Youcan find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Read over the information we send you about any other insurance coverage youhaveMedicare requires that we collect information from you about any other medical or drug insurancecoverage that you have. That’s because we must coordinate any other coverage you have with yourbenefits under our plan. (For more information about how our coverage works when you have otherinsurance, see Section 7 in this chapter.)

Once each year, we will send you a letter that lists any other medical or drug insurance coveragethat we know about. Please read over this information carefully. If it is correct, you don’t need todo anything. If the information is incorrect, or if you have other coverage that is not listed, pleasecall Customer Service (phone numbers are printed on the back cover of this booklet).

SECTION 6 We protect the privacy of your personal health information

Section 6.1 We make sure that your health information is protected

Federal and state laws protect the privacy of your medical records and personal health information.We protect your personal health information as required by these laws.

For more information about howwe protect your personal health information, please go to Chapter 8,Section 1.4 of this booklet.

SECTION 7 How other insurance works with our plan

Section 7.1 Which plan pays first when you have other insurance?

When you have other insurance (like employer group health coverage), there are rules set byMedicare that decide whether our plan or your other insurance pays first. The insurance that paysfirst is called the “primary payer” and pays up to the limits of its coverage. The one that pays second,called the “secondary payer,” only pays if there are costs left uncovered by the primary coverage.The secondary payer may not pay all of the uncovered costs.

These rules apply for employer or union group health plan coverage:

1 If you have retiree coverage, Medicare pays first.

1 If your group health plan coverage is based on your or a familymember’s current employment,who pays first depends on your age, the number of people employed by your employer, andwhether you have Medicare based on age, disability, or End-stage Renal Disease (ESRD):


If you’re under 65 and disabled and you or your family member is still working, yourgroup health plan pays first if the employer has 100 or more employees or at least oneemployer in a multiple employer plan that has more than 100 employees.

4

4 If you’re over 65 and you or your spouse is still working, your group health plan paysfirst if the employer has 20 or more employees or at least one employer in a multipleemployer plan that has more than 20 employees.

1 If you have Medicare because of ESRD, your group health plan will pay first for the first 30months after you become eligible for Medicare.

These types of coverage usually pay first for services related to each type:

1 No-fault insurance (including automobile insurance)

1 Liability (including automobile insurance)

1 Black lung benefits

1 Workers’ compensation

Medicaid and TRICARE never pay first for Medicare-covered services. They only pay afterMedicare, employer group health plans, and/or Medigap have paid.

If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions aboutwho pays first, or you need to update your other insurance information, call Customer Service(phone numbers are printed on the back cover of this booklet). You may need to give your planmember ID number to your other insurers (once you have confirmed their identity) so your billsare paid correctly and on time.


CHAPTER 2Important phone numbers

and resources

Chapter 2. Important phone numbers and resources

SECTION 1 Memorial Hermann Advantage PPO contacts (how to contact us,including how to reach Customer Service at the plan) .................... 19

SECTION 2 Medicare (how to get help and information directly from theFederal Medicare program) .................................................................24

SECTION 3 State Health InsuranceAssistance Program (free help, information,and answers to your questions about Medicare) ............................. 25

SECTION 4 Quality Improvement Organization (paid by Medicare to check onthe quality of care for people with Medicare) .................................... 26

SECTION 5 Social Security .....................................................................................27

SECTION 6 Medicaid (a joint Federal and state program that helpswithmedicalcosts for some people with limited income and resources) ............ 28

SECTION 7 Information about programs to help people pay for theirprescription drugs ...............................................................................28

SECTION 8 How to contact the Railroad Retirement Board ................................ 31

SECTION 9 Do you have “group insurance” or other health insurance froman employer? ........................................................................................32

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 18Chapter 2. Important phone numbers and resources

SECTION 1 Memorial Hermann Advantage PPO contacts(how to contact us, including how to reach Customer Serviceat the plan)

How to contact our plan’s Customer ServiceFor assistance with claims, billing or member card questions, please call or write to MemorialHermann Advantage PPO Customer Service. We will be happy to help you.

Customer Service – Contact InformationMethod

(844) 550-6896CALL

Calls to this number are free. 8 a.m. to 8 p.m. seven days a week

Customer Service also has free language interpreter services available fornon-English speakers.

711TTY/TDD


(713)338-6550FAX

Memorial Hermann Advantage PPO7737 Southwest FreewaySuite C-97Houston, TX 77074

WRITE

healthplan.memorialhermann.org/medicareWEBSITE

How to contact us when you are asking for a coverage decision about your medicalcareA coverage decision is a decision we make about your benefits and coverage or about the amountwe will pay for your medical services. For more information on asking for coverage decisions aboutyour medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions,appeals, complaints)).

You may call us if you have questions about our coverage decision process.

Coverage Decisions for Medical Care – Contact InformationMethod

(844) 550-6896CALL


711TTY/TDD


(713) 338-6982FAX


Coverage Decisions for Medical Care – Contact InformationMethod

Memorial Hermann Advantage PPOMedical Management7737 Southwest FreewaySuite C-97Houston, TX 77074

WRITE


How to contact us when you are making an appeal about your medical careAn appeal is a formal way of asking us to review and change a coverage decision we have made.For more information on making an appeal about your medical care, see Chapter 9 (What to do ifyou have a problem or complaint (coverage decisions, appeals, complaints)).

Appeals for Medical Care – Contact InformationMethod

(844) 550-6896CALL


711TTY/TDD


(713) 338-5812FAX

Memorial Hermann Advantage PPOAppeals & Grievances7737 Southwest FreewaySuite C-97Houston, TX 77074

WRITE


How to contact us when you are making a complaint about your medical careYou can make a complaint about us or one of our network providers, including a complaint aboutthe quality of your care. This type of complaint does not involve coverage or payment disputes. (Ifyou have a problem about the plan’s coverage or payment, you should look at the section aboveabout making an appeal.) For more information on making a complaint about your medical care,see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,complaints)).

Complaints about Medical Care – Contact InformationMethod

(844) 550-6896CALL


711TTY/TDD


Complaints about Medical Care – Contact InformationMethod


(713) 338-5812FAX

Memorial Hermann Advantage PPOAppeals & Grievances7737 Southwest FreewaySuite C-97Houston, TX 77074

WRITE

You can submit a complaint about Memorial Hermann AdvantagePPO directly to Medicare. To submit an online complaint to Medicare goto www.medicare.gov/MedicareComplaintForm/home.aspx.

MEDICAREWEBSITE

How to contact us when you are asking for a coverage decision about your Part Dprescription drugsA coverage decision is a decision we make about your benefits and coverage or about the amountwe will pay for your prescription drugs covered under the Part D benefit included in your plan. Formore information on asking for coverage decisions about your Part D prescription drugs, seeChapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

Coverage Decisions for Part D Prescription Drugs – ContactInformation

Method

(844) 782-7672CALL

Calls to this number are free. Hours of operation are 24 hours a day, 7 daysa week.

711TTY/TDD

Calls to this number are free. Hours of operation are 24 hours a day, 7 daysa week.

(877) 503-7231FAX

Envision Rx OptionsAttn: Coverage Determinations (Clinical Services)2181 E. Aurora Road, Suite 201Twinsburg, OH 44087

WRITE


How to contact us when you are making an appeal about your Part D prescriptiondrugsAn appeal is a formal way of asking us to review and change a coverage decision we have made.For more information on making an appeal about your Part D prescription drugs, see Chapter 9(What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).


Appeals for Part D Prescription Drugs – Contact InformationMethod

(844) 550-6896CALL


711TTY/TDD


(713) 338-5812FAX

Memorial Hermann Advantage PPOAppeals & Grievances7737 Southwest FreewaySuite C-97Houston, Texas 77074

WRITE


How to contact us when you are making a complaint about your Part D prescriptiondrugsYou can make a complaint about us or one of our network pharmacies, including a complaint aboutthe quality of your care. This type of complaint does not involve coverage or payment disputes. (Ifyour problem is about the plan’s coverage or payment, you should look at the section above aboutmaking an appeal.) For more information on making a complaint about your Part D prescriptiondrugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,complaints)).

Complaints about Part D prescription drugs – Contact InformationMethod

(844) 550-6896CALL


711TTY/TDD


(713) 338-5812FAX

Memorial Hermann Advantage PPOAppeals & Grievances7737 Southwest FreewaySuite C-97Houston, Texas 77074

WRITE

You can submit a complaint about Memorial Hermann Advantage PPOdirectly to Medicare. To submit an online complaint to Medicare, go towww.medicare.gov/MedicareComplaintForm/home.aspx.

MEDICAREWEBSITE


Where to send a request asking us to pay for our share of the cost for medical careor a drug you have receivedFor more information on situations in which you may need to ask us for reimbursement or to paya bill you have received from a provider, see Chapter 7 (Asking us to pay our share of a bill youhave received for covered medical services or drugs).

Please note: If you send us a payment request and we deny any part of your request, you can appealour decision. See Chapter 9 (What to do if you have a problem or complaint (coverage decisions,appeals, complaints)) for more information.

Payment Request – Contact InformationMethod

(844) 550-6896CALL

8 a.m. to 8 p.m. seven days a week

Calls to this number are free.

711TTY/TDD


(713) 338-5188FAX

Memorial Hermann Advantage EnrollmentP.O. Box 223567Dallas, TX 75222-3567

WRITE


Payment Requests – Part D Prescription Drugs Contact InformationMethod

(844) 550-6896CALL


24 hours a day, 7 days a week.

711TTY/TDD



(877) 503-7231FAX

EnvisionAttn: Member Reimbursement Department2181 E. Aurora Road, Suite 201Twinsburg, OH 44087

WRITE


Payment Requests – Part D Prescription Drugs Contact InformationMethod


SECTION 2 Medicare(how to get help and information directly from the FederalMedicare program)

Medicare is the Federal health insurance program for people 65 years of age or older, some peopleunder age 65 with disabilities, and people with End-Stage Renal Disease (permanent kidney failurerequiring dialysis or a kidney transplant).

The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services(sometimes called “CMS”). This agency contracts withMedicare Advantage organizations includingus.

Medicare – Contact InformationMethod

1-800-MEDICARE, or 1-800-633-4227CALL



1-877-486-2048TTY/TDD

This number requires special telephone equipment and is only for people whohave difficulties with hearing or speaking.


http://www.medicare.govWEBSITE

This is the official government website for Medicare. It gives you up-to-dateinformation about Medicare and current Medicare issues. It also has informationabout hospitals, nursing homes, physicians, home health agencies, and dialysisfacilities. It includes booklets you can print directly from your computer. You canalso find Medicare contacts in your state.

TheMedicare website also has detailed information about yourMedicare eligibilityand enrollment options with the following tools:

1 Medicare Eligibility Tool: ProvidesMedicare eligibility status information.

1 Medicare Plan Finder: Provides personalized information about availableMedicare prescription drug plans, Medicare health plans, and Medigap(Medicare Supplement Insurance) policies in your area. These tools providean estimate of what your out-of-pocket costs might be in different Medicareplans.


Medicare – Contact InformationMethod

You can also use the website to tell Medicare about any complaints you have aboutMemorial Hermann Advantage PPO:

1 Tell Medicare about your complaint: You can submit a complaint aboutMemorial Hermann Advantage PPO directly to Medicare. To submit acomplaint toMedicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use thisinformation to help improve the quality of the Medicare program.

If you don’t have a computer, your local library or senior center may be able tohelp you visit this website using its computer. Or, you can call Medicare and tellthem what information you are looking for. They will find the information on thewebsite, print it out, and send it to you. (You can call Medicare at1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY usersshould call 1-877-486-2048.)

1 Minimum essential coverage (MCE): Coverage under this Plan qualifiesas minimum essential coverage (MEC) and satisfies the Patient Protectionand Affordable Care Act’s (ACA) individual shared responsibilityrequirement. Please visit the Internal Revenue Service (IRS) website at http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provisionfor more information on the individual requirement for MEC.

SECTION 3 State Health Insurance Assistance Program(free help, information, and answers to your questions aboutMedicare)

The State Health Insurance Assistance Program (SHIP) is a government program with trainedcounselors in every state. In Texas, the SHIP is called Health Information Counseling and AdvocacyProgram (HICAP).

Health Information Counseling and Advocacy Program (HICAP) is independent (not connectedwith any insurance company or health plan). It is a state program that gets money from the Federalgovernment to give free local health insurance counseling to people with Medicare.

Health Information Counseling and Advocacy Program (HICAP) counselors can help you withyour Medicare questions or problems. They can help you understand your Medicare rights, helpyou make complaints about your medical care or treatment, and help you straighten out problemswith your Medicare bills. Health Information Counseling and Advocacy Program (HICAP)counselors can also help you understand your Medicare plan choices and answer questions aboutswitching plans.


Health Information Counseling and Advocacy Program (HICAP):(Texas SHIP) – Contact Information

Method

(800) 252-9240CALL

(512) 438-3011

TTY: 711TTY/TDD

701 W. 51st St., Austin, Texas 78751WRITE

http://www.dads.state.tx.us/WEBSITE

SECTION 4 Quality Improvement Organization(paid by Medicare to check on the quality of care for peoplewith Medicare)

There is a designated Quality Improvement Organization for servingMedicare beneficiaries in eachstate. For Texas, the Quality Improvement Organization is called KEPRO.

KEPRO has a group of doctors and other health care professionals who are paid by the Federalgovernment. This organization is paid by Medicare to check on and help improve the quality ofcare for people with Medicare. KEPRO is an independent organization. It is not connected withour plan.

You should contact KEPRO in any of these situations:

1 You have a complaint about the quality of care you have received.

1 You think coverage for your hospital stay is ending too soon.

1 You think coverage for your home health care, skilled nursing facility care, or ComprehensiveOutpatient Rehabilitation Facility (CORF) services are ending too soon.

KEPRO: (Texas’s Quality Improvement Organization) – ContactInformation

Method

(844) 430-9504CALL

(855) 843-4776TTY

This number requires special telephone equipment and is only for peoplewho have difficulties with hearing or speaking.

Rock Run Center, Suite 1005700 Lombardo Center Dr.Seven Hills, OH 44131

WRITE


KEPRO: (Texas’s Quality Improvement Organization) – ContactInformation

Method

http://www.keproqio.com/bene/statelisting.aspx?state=TexasWEBSITE

SECTION 5 Social Security

Social Security is responsible for determining eligibility and handling enrollment for Medicare.U.S. citizens who are 65 or older, or who have a disability or End-Stage Renal Disease and meetcertain conditions, are eligible for Medicare. If you are already getting Social Security checks,enrollment into Medicare is automatic. If you are not getting Social Security checks, you have toenroll in Medicare. Social Security handles the enrollment process for Medicare. To apply forMedicare, you can call Social Security or visit your local Social Security office.

Social Security is also responsible for determining who has to pay an extra amount for their Part Ddrug coverage because they have a higher income. If you got a letter from Social Security tellingyou that you have to pay the extra amount and have questions about the amount or if your incomewent down because of a life-changing event, you can call Social Security to ask for a reconsideration.

If you move or change your mailing address, it is important that you contact Social Security to letthem know.

Social Security – Contact InformationMethod

1-800-772-1213CALL


Available 7:00 am to 7:00 pm, Monday through Friday.

You can use Social Security’s automated telephone services to get recordedinformation and conduct some business 24 hours a day.

1-800-325-0778TTY/TDD



Available 7:00 am to 7:00 pm, Monday through Friday.

http://www.ssa.govWEBSITE


SECTION 6 Medicaid(a joint Federal and state program that helps with medical costsfor some people with limited income and resources)

Medicaid is a joint Federal and state government program that helps with medical costs for certainpeople with limited incomes and resources. Some people with Medicare are also eligible forMedicaid.

In addition, there are programs offered through Medicaid that help people with Medicare pay theirMedicare costs, such as their Medicare premiums. These “Medicare Savings Programs” help peoplewith limited income and resources save money each year:

1 QualifiedMedicare Beneficiary (QMB):Helps payMedicare Part A and Part B premiums,and other cost-sharing (like deductibles, coinsurance, and copayments). (Some people withQMB are also eligible for full Medicaid benefits (QMB+).)

1 Specified Low-IncomeMedicare Beneficiary (SLMB):Helps pay Part B premiums. (Somepeople with SLMB are also eligible for full Medicaid benefits (SLMB+).)

1 Qualified Individual (QI): Helps pay Part B premiums.

1 Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums.

To find out more aboutMedicaid and its programs, contact Health and Human Services Commissionof Texas.

Health and Human Services Commission of Texas: (Texas’s Medicaidprogram) – Contact Information

Method

(877) 541-7905CALL

(512) 424-6500

TTY (512) 407-3250TTY


P.O. Box 14200, Midland, TX 79711-4200WRITE

http://www.hhsc.state.tx.us/medicaid/WEBSITE

SECTION 7 Information about programs to help people pay for theirprescription drugs

Medicare’s “Extra Help” ProgramMedicare provides “Extra Help” to pay prescription drug costs for people who have limited incomeand resources. Resources include your savings and stocks, but not your home or car. If you qualify,


you get help paying for any Medicare drug plan’s monthly premium, yearly deductible, andprescription copayments. This “Extra Help” also counts toward your out-of-pocket costs.

People with limited income and resources may qualify for “Extra Help.” Some people automaticallyqualify for “Extra Help” and don’t need to apply.Medicare mails a letter to people who automaticallyqualify for “Extra Help.”

You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To seeif you qualify for getting “Extra Help,” call:

1 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24hours a day, 7 days a week;

1 The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday throughFriday. TTY/TDD users should call 1-800-325-0778 (applications); or

1 Your State Medicaid Office (applications). (See Section 6 of this chapter for contactinformation.)

If you believe you have qualified for “Extra Help” and you believe that you are paying an incorrectcost-sharing amount when you get your prescription at a pharmacy, our plan has established aprocess that allows you to either request assistance in obtaining evidence of your proper copaymentlevel, or, if you already have the evidence, to provide this evidence to us.

Below are some examples of the types of documentation (also known as “Best Available Evidence”)that can be used to prove you qualify for Extra Help.

1 A copy of your Medicaid card which includes your name and an eligibility date during thediscrepant period;

1 A copy of a State document that confirms activeMedicaid status during the discrepant period;

1 A printout from the State’s electronic file showing Medicaid status during the discrepantperiod;

1 A screen print from the State’sMedicaid system showingMedicaid status during the discrepantperiod;

1 Other documentation from the State showing Medicaid status during the discrepant period.

1 When we receive the evidence showing your copayment level, we will update our system sothat you can pay the correct copayment when you get your next prescription at the pharmacy.If you overpay your copayment, we will reimburse you. Either we will forward a check toyou in the amount of your overpayment or we will offset future copayments. If the pharmacyhasn’t collected a copayment from you and is carrying your copayment as a debt owed byyou, we may make the payment directly to the pharmacy. If a state paid on your behalf, wemaymake payment directly to the state. Please contact Customer Service if you have questions(phone numbers are printed on the back cover of this booklet).

Medicare Coverage Gap Discount ProgramThe Medicare Coverage Gap Discount Program provides manufacturer discounts on brand namedrugs to Part D enrollees who have reached the coverage gap and are not receiving “Extra Help.”


A 50% discount on the negotiated price (excluding the dispensing fee) is available for those brandname drugs from manufacturers. The plan pays an additional 5% and you pay the remaining 45%for your brand drugs.

If you reach the coverage gap, we will automatically apply the discount when your pharmacy billsyou for your prescription and your Part D Explanation of Benefits (Part D EOB) will show anydiscount provided. Both the amount you pay and the amount discounted by the manufacturer counttoward your out-of-pocket costs as if you had paid them and moves you through the coverage gap.The amount paid by the plan (5%) does not count toward your out-of-pocket costs.

You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays42% of the price for generic drugs and you pay the remaining 58% of the price. For generic drugs,the amount paid by the plan (42%) does not count toward your out-of-pocket costs. Only the amountyou pay counts and moves you through the coverage gap. Also, the dispensing fee is included aspart of the cost of the drug.

TheMedicare CoverageGapDiscount Program is available nationwide. BecauseMemorial HermannAdvantage PPO offers additional gap coverage during the Coverage Gap Stage, your out-of-pocketcosts will sometimes be lower than the costs described here. Please go to Chapter 6, Section 6 formore information about your coverage during the Coverage Gap Stage.

If you have any questions about the availability of discounts for the drugs you are taking or aboutthe Medicare Coverage Gap Discount Program in general, please contact Customer Service (phonenumbers are printed on the back cover of this booklet).

What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?

If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other programthat provides coverage for Part D drugs (other than “Extra Help”), you still get the 50% discounton covered brand name drugs. Also, the plan pays 5% of the costs of brand drugs in the coveragegap. The 50% discount and the 5% paid by the plan are both applied to the price of the drug beforeany SPAP or other coverage.

What if you have coverage from an AIDS Drug Assistance Program (ADAP)?

What is the AIDS Drug Assistance Program (ADAP)?

The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that are alsocovered by ADAP qualify for prescription cost-sharing assistance Texas HIVMedication Program(THMP). Note: To be eligible for the ADAP operating in your State, individuals must meet certaincriteria, including proof of State residence and HIV status, low income as defined by the State, anduninsured/under-insured status.

If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part Dprescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure youcontinue receiving this assistance, please notify your local ADAP enrollment worker of any changesin your Medicare Part D plan name or policy number. If you have questions or need assistancecompleting an application for the Texas HIV Medication Program (THMP), call THMP toll freeat (800) 255-1090.


What if you get “Extra Help” from Medicare to help pay your prescription drug costs? Canyou get the discounts?

No. If you get “Extra Help,” you already get coverage for your prescription drug costs during thecoverage gap.

What if you don’t get a discount, and you think you should have?

If you think that you have reached the coverage gap and did not get a discount when you paid foryour brand name drug, you should review your next Part D Explanation of Benefits (Part D EOB)notice. If the discount doesn’t appear on your Part D Explanation of Benefits, you should contactus to make sure that your prescription records are correct and up-to-date. If we don’t agree that youare owed a discount, you can appeal. You can get help filing an appeal from your State HealthInsurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this Chapter) or bycalling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD usersshould call 1-877-486-2048.

State Pharmaceutical Assistance ProgramsMany states have State Pharmaceutical Assistance Programs that help some people pay forprescription drugs based on financial need, age, medical condition, or disabilities. Each state hasdifferent rules to provide drug coverage to its members.

In Texas, the State Pharmaceutical Assistance Program is Texas HIV State Pharmacy AssistanceProgram (SPAP).

TexasHIV State PharmacyAssistance Program (SPAP): (Texas’s StatePharmaceutical Assistance Program) – Contact Information

Method

(800) 255-1090CALL

(512) 533-3000

TTY:711TTY

P.O. Box 149347, MC 1873, Austin, TX 78714WRITE

http://www.dshs.state.tx.us/hivstd/meds/spap.shtmWEBSITE

SECTION 8 How to contact the Railroad Retirement Board

The Railroad Retirement Board is an independent Federal agency that administers comprehensivebenefit programs for the nation’s railroad workers and their families. If you have questions regardingyour benefits from the Railroad Retirement Board, contact the agency.

If you receive your Medicare through the Railroad Retirement Board, it is important that you letthem know if you move or change your mailing address


Railroad Retirement Board – Contact InformationMethod

1-877-772-5772CALL


Available 9:00 am to 3:30 pm, Monday through Friday

If you have a touch-tone telephone, recorded information and automatedservices are available 24 hours a day, including weekends and holidays.

1-312-751-4701TTY/TDD


Calls to this number are not free.

http://www.rrb.govWEBSITE

SECTION 9 Do you have “group insurance” or other health insurancefrom an employer?

If you (or your spouse) get benefits from your (or your spouse’s) employer or retiree group as partof this plan, you may call the employer/union benefits administrator or Customer Service if youhave any questions. You can ask about your (or your spouse’s) employer or retiree health benefits,premiums, or the enrollment period. (Phone numbers for Customer Service are printed on the backcover of this booklet.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY/TDD:1-877-486-2048) with questions related to your Medicare coverage under this plan. If you haveother prescription drug coverage through your (or your spouse’s) employer or retiree group, pleasecontact that group’s benefits administrator. The benefits administrator can help you determinehow your current prescription drug coverage will work with our plan.


CHAPTER 3Using the plan’s

coverage for yourmedical services

Chapter 3. Using the plan’s coverage for your medical services

SECTION 1 Things to know about getting your medical care covered as amember of our plan ..............................................................................36

Section 1.1 What are “network providers” and “covered services”? ................................ 36

Section 1.2 Basic rules for getting your medical care covered by the plan ....................... 36

SECTION 2 Using network and out-of-network providers to get your medicalcare ........................................................................................................37

Section 2.1 You must choose a Primary Care Provider (PCP) to provide and overseeyour medical care ............................................................................................ 37

Section 2.2 What kinds of medical care can you get without getting approval in advancefrom your PCP? .............................................................................................. 38

Section 2.3 How to get care from specialists and other network providers ...................... 38

Section 2.4 How to get care from out-of-network providers ............................................. 39

SECTION 3 How to get covered services when you have an emergency orurgent need for care or during a disaster .......................................... 40

Section 3.1 Getting care if you have a medical emergency ............................................... 40

Section 3.2 Getting care when you have an urgent need for services ............................... 41

Section 3.3 Getting care during a disaster ......................................................................... 42

SECTION 4 What if you are billed directly for the full cost of your coveredservices? ...............................................................................................43

Section 4.1 You can ask us to pay our share of the cost of covered services .................... 43

Section 4.2 If services are not covered by our plan, you must pay the full cost ............... 43

SECTION 5 How are yourmedical services coveredwhen you are in a “clinicalresearch study”? ..................................................................................43

Section 5.1 What is a “clinical research study”? ............................................................... 43

Section 5.2 When you participate in a clinical research study, who pays for what? ......... 44

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 34Chapter 3. Using the plan’s coverage for your medical services

SECTION 6 Rules for getting care covered in a “religious non-medical healthcare institution” ....................................................................................45

Section 6.1 What is a religious non-medical health care institution? ................................ 45

Section 6.2 What care from a religious non-medical health care institution is coveredby our plan? .................................................................................................... 46

SECTION 7 Rules for ownership of durable medical equipment ........................ 46

Section 7.1 Will you own the durable medical equipment after making a certain numberof payments under our plan? ......................................................................... 46


SECTION 1 Things to know about getting your medical care coveredas a member of our plan

This chapter explains what you need to know about using the plan to get your medical care coverage.It gives definitions of terms and explains the rules you will need to follow to get the medicaltreatments, services, and other medical care that are covered by the plan.

For the details on what medical care is covered by our plan and how much you pay when you getthis care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what iscovered and what you pay).

Section 1.1 What are “network providers” and “covered services”?

Here are some definitions that can help you understand how you get the care and services that arecovered for you as a member of our plan:

1 “Providers” are doctors and other health care professionals licensed by the state to providemedical services and care. The term “providers” also includes hospitals and other health carefacilities.

1 “Network providers” are the doctors and other health care professionals, medical groups,hospitals, and other health care facilities that have an agreement with us to accept our paymentand your cost-sharing amount as payment in full. We have arranged for these providers todeliver covered services to members in our plan. The providers in our network bill us directlyfor care they give you. When you see a network provider, you pay only your share of thecost for their services.

1 “Covered services” include all the medical care, health care services, supplies, and equipmentthat are covered by our plan. Your covered services for medical care are listed in the benefitschart in Chapter 4.

Section 1.2 Basic rules for getting your medical care covered by the plan

As a Medicare health plan, Memorial Hermann Advantage PPO must cover all services coveredby Original Medicare and must follow Original Medicare’s coverage rules.

Memorial Hermann Advantage PPO will generally cover your medical care as long as:

1 The care you receive is included in the plan’s Medical Benefits Chart (this chart is inChapter 4 of this booklet).

1 The care you receive is considered medically necessary. “Medically necessary” meansthat the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment ofyour medical condition and meet accepted standards of medical practice.

1 You receive your care from a provider who is eligible to provide services under OriginalMedicare.As amember of our plan, you can receive your care from either a network provideror an out-of-network provider (for more about this, see Section 2 in this chapter).


The providers in our network are listed in the Provider Directory.4

4 If you use an out-of-network provider, your share of the costs for your covered servicesmay be higher.

4 Please note:While you can get your care from an out-of-network provider, the providermust be eligible to participate in Medicare. Except for emergency care, we cannot pay aprovider who is not eligible to participate in Medicare. If you go to a provider who is noteligible to participate in Medicare, you will be responsible for the full cost of the servicesyou receive. Check with your provider before receiving services to confirm that they areeligible to participate in Medicare.

SECTION 2 Using network and out-of-network providers to get yourmedical care

Section 2.1 You must choose a Primary Care Provider (PCP) to provide andoversee your medical care

What is a “PCP” and what does the PCP do for you?

A PCP is your primary health care provider who specializes in Family Practice, General Practice,Internal Medicine, Nurse Practitioner (NP), Physician Assistant (PA), or Geriatrics. A PCP is theprimary health care provider who manages your general health care, meets state requirements, andis trained in the treatment of routine illnesses and injuries. Your PCP coordinates services andaccess to care and is responsible for arranging for a backup PCP when he or she is not or will notbe available. You will receive your routine or basic care from your PCP. Your PCP will providemost of your care and will talk with other doctors and health care providers about your care. He orshe makes sure you get the care you need and will help to arrange or coordinate the rest of thecovered services you receive as a member of our Plan. This includes:

1 X-rays

1 Laboratory tests

1 Therapies

1 Specialty Care

1 Hospital admissions

1 Follow-up care

Your PCP also ‘coordinates’ your services which includes checking or consulting with other healthcare providers for updates about your care and/or treatments. In some cases, your PCP will needto obtain prior approval (prior authorization) fromMemorial Hermann Advantage PPO. Since yourPCPwill provide and coordinate your medical care, you should have all of your past medical recordssent to your PCP office.


How do you choose your PCP?

As a member of Memorial Hermann Advantage PPO, you choose a PCP by using the ProviderDirectory, going online at healthplan.memorialhermann.org/medicare, or by contacting our CustomerService Department where a representative can assist you with your selection.

Customer Service will also check to see if a provider is participating in our network of providersas well as accepting new patients. The Customer Service telephone number is printed on the backcover of this booklet. If there is a particular specialist or hospital that you want to use, check firstto be sure your PCP uses that specialist or hospital.

Changing your PCP

You may change your PCP for any reason, at any time. Also, it’s possible that your PCP mightleave our plan’s network of providers and you would have to find a new PCP in our plan.

If you wish to change your PCP, please contact our Customer Service Department where arepresentative can assist you with making this change. PCP changes are effective the first of themonth following the date of the request when received by the 20th of the month. (Phone numbersfor Customer Service are printed on the back cover of this booklet.)

Section 2.2 What kinds of medical care can you get without getting approval inadvance from your PCP?

You can get the services listed below without getting approval in advance from your PCP.

1 Routine women’s health care, which includes breast exams, screening mammograms (x-raysof the breast), Pap tests, and pelvic exams.

1 Flu shots, Hepatitis B vaccinations and pneumonia vaccinations.

1 Emergency services from network providers or from out-of-network providers.

1 Urgently needed services from network providers or from out-of-network providers whennetwork providers are temporarily unavailable or inaccessible, e.g., when you are temporarilyoutside of the plan’s service area.

1 Kidney dialysis services that you get at a Medicare-certified dialysis facility when you aretemporarily outside the plan’s service area. If possible, please call Customer Service beforeyou leave the service area so we can help arrange for you to have maintenance dialysis whileyou are away. Phone numbers for Customer Service are printed on the back cover of thisbooklet.

Section 2.3 How to get care from specialists and other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the body.There are many kinds of specialists. Here are a few examples:

1 Oncologists care for patients with cancer.


1 Cardiologists care for patients with heart conditions.

1 Orthopedists care for patients with certain bone, joint, or muscle conditions.

See your Provider Directory and our website for information about our network of health careproviders and specialists. Your PCP is trained to handle the majority of common health care needs,and there may be a time when he or she feels you need more specialized treatment. In that case,your PCP may refer you to a network specialist.

For some types of visits or procedures, your PCP or Specialist may need to get approval in advancefrom our Plan (prior authorization). Plan authorizationmay be granted for a certain number of visitsor procedures. Should additional visits or procedures may be required, your PCP or the specialistmay need to request approval from the plan again. See the benefits chart in Chapter 4, Section 2.1to learn which services may need prior authorization.

What if a specialist or another network provider leaves our plan?

We may make changes to the hospitals, doctors, and specialists (providers) that are part of yourplan during the year. There are a number of reasons why your provider might leave your plan butif your doctor or specialist does leave your plan you have certain rights and protections that aresummarized below:

1 Even though our network of providers may change during the year, Medicare requires thatwe furnish you with uninterrupted access to qualified doctors and specialists.

1 When possible we will provide you with at least 30 days’ notice that your provider is leavingour plan so that you have time to select a new provider.

1 We will assist you in selecting a new qualified provider to continue managing your healthcare needs.

1 If you are undergoing medical treatment you have the right to request, and we will work withyou to ensure, that the medically necessary treatment you are receiving is not interrupted.

1 If you believe we have not furnished you with a qualified provider to replace your previousprovider or that your care is not being appropriately managed you have the right to file anappeal of our decision.

1 If you find out that your doctor or specialist is leaving your plan please contact us so we canassist you in finding a new provider and managing your care.

For any needed assistance please contact our Customer Service Department. (Phone numbers forCustomer Service are printed on the back cover of this booklet.)

Section 2.4 How to get care from out-of-network providers

As a member of our plan, you can choose to receive care from out-of-network providers. Our planwill cover services from either network or out-of-network providers, as long as the services arecovered benefits and are medically necessary. However, if you use an out-of-network provider,


your share of the costs for your covered services may be higher.Here are other important thingsto know about using out-of-network providers:

1 You can get your care from an out-of-network provider, however, in most cases that providermust be eligible to participate in Medicare. Except for emergency care, we cannot pay aprovider who is not eligible to participate in Medicare. If you receive care from a providerwho is not eligible to participate in Medicare, you will be responsible for the full cost of theservices you receive. Check with your provider before receiving services to confirm that theyare eligible to participate in Medicare.

1 You don’t need to get a referral or prior authorization when you get care from out-of-networkproviders. However, before getting services from out-of-network providers you may wantto ask for a pre-visit coverage decision to confirm that the services you are getting are coveredand are medically necessary. (See Chapter 9, Section 4 for information about asking forcoverage decisions.) This is important because:

4 Without a pre-visit coverage decision, if we later determine that the services are notcovered or were not medically necessary, we may deny coverage and you will beresponsible for the entire cost. If we say we will not cover your services, you have theright to appeal our decision not to cover your care. See Chapter 9 (What to do if you havea problem or complaint) to learn how to make an appeal.

1 It is best to ask an out-of-network provider to bill the plan first. But, if you have already paidfor the covered services, we will reimburse you for our share of the cost for covered services.Or if an out-of-network provider sends you a bill that you think we should pay, you can sendit to us for payment. See Chapter 7 (Asking us to pay our share of a bill you have receivedfor covered medical services or drugs) for information about what to do if you receive a billor if you need to ask for reimbursement.

1 If you are using an out-of-network provider for emergency care, urgently needed services,or out-of-area dialysis, you may not have to pay a higher cost-sharing amount. See Section 3for more information about these situations.

SECTION 3 How to get covered services when you have an emergencyor urgent need for care or during a disaster

Section 3.1 Getting care if you have a medical emergency

What is a “medical emergency” and what should you do if you have one?A “medical emergency” is when you, or any other prudent layperson with an average knowledgeof health and medicine, believe that you have medical symptoms that require immediate medicalattention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptomsmay be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

If you have a medical emergency:


1 Get help as quickly as possible. Call 911 for help or go to the nearest emergency room orhospital. Call for an ambulance if you need it. You do not need to get approval or a referralfirst from your PCP.

1 As soon as possible, make sure that our plan has been told about youremergency.We need to follow up on your emergency care. You or someone else should callto tell us about your emergency care, usually within 48 hours.

What is covered if you have a medical emergency?You may get covered emergency medical care whenever you need it, anywhere in the United Statesor its territories. Our plan covers ambulance services in situations where getting to the emergencyroom in any other way could endanger your health. For more information, see the Medical BenefitsChart in Chapter 4 of this booklet.

In addition, our Plan offers coverage for emergency medical care worldwide whenever you needit. For more information about this benefit, see Chapter 4, Medical Benefits for more information.

If you have an emergency, we will talk with the doctors who are giving you emergency care to helpmanage and follow up on your care. The doctors who are giving you emergency care will decidewhen your condition is stable and the medical emergency is over.

After the emergency is over you are entitled to follow-up care to be sure your condition continuesto be stable. Your follow-up care will be covered by our plan. If you get your follow-up care fromout-of-network providers, you will pay the higher out-of-network cost-sharing.

What if it wasn’t a medical emergency?Sometimes it can be hard to know if you have a medical emergency. For example, you might goin for emergency care – thinking that your health is in serious danger – and the doctor may say thatit wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long as youreasonably thought your health was in serious danger, we will cover your care.

However, after the doctor has said that it was not an emergency, the amount of cost-sharing thatyou paywill depend onwhether you get the care from network providers or out-of-network providers.If you get the care from network providers, your share of the costs will usually be lower than if youget the care from out-of-network providers.

Section 3.2 Getting care when you have an urgent need for services

What are “urgently needed services”?“Urgently needed services” are non-emergency, unforeseen medical illness, injury, or conditionthat requires immediate medical care. Urgently needed services may be furnished by networkproviders or by out-of-network providers when network providers are temporarily unavailable orinaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a knowncondition that you have.

What if you are in the plan’s service area when you have an urgent need for care?


In most situations, if you are in the plan’s service area and you use an out-of-network provider,you will pay a higher share of the costs for your care.

However, if the circumstances are unusual or extraordinary, and network providers are temporarilyunavailable or inaccessible, we will allow you to get covered services from an out-of-networkprovider at the lower in-network cost-sharing amount.

You can receive care from any urgent care provider included in your provider directory. Werecommend you contact your PCP’s office if you need urgent care. If urgent care services arereceived in your doctor’s office, you will pay the office cost share amount; however, if urgent careservices are received at a plan urgent care center, you will pay the urgent care center cost shareamount, which may be higher. You can receive care from any urgent care provider included in yourprovider directory. If you are having trouble finding a network urgent care provider, please callCustomer Service at the phone number printed on the back cover of this booklet. See Chapter 4.Medical Benefits Chart (what is covered and what you pay) for the co-payment that applies toservices provided in a doctor’s office or Plan urgent care center.

What if you are outside the plan’s service area when you have an urgent need forcare?When you are outside the service area and cannot get care from a network provider, our plan willcover urgently needed services that you get from any provider at the lower in-network cost-sharingamount.

In addition, our Plan offers coverage for emergency care worldwide whenever you need it. Formore information about this benefit, see Chapter 4. Medical Benefits Chart (what is covered andwhat you pay).

Section 3.3 Getting care during a disaster

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the Presidentof the United States declares a state of disaster or emergency in your geographic area, you are stillentitled to care from your plan.

Please visit the following website: healthplan.memorialhermann.org/medicare for information onhow to obtain needed care during a disaster.

Generally, during a disaster, your plan will allow you to obtain care from out-of-network providersat in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may beable to fill your prescription drugs at an out-of-network pharmacy. Please see Chapter 5, Section 2.5for more information.


SECTION 4 What if you are billed directly for the full cost of yourcovered services?

Section 4.1 You can ask us to pay our share of the cost of covered services

If you have paid more than your share for covered services, or if you have received a bill for thefull cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you havereceived for covered medical services or drugs) for information about what to do.

Section 4.2 If services are not covered by our plan, you must pay the full cost

Memorial Hermann Advantage PPO covers all medical services that are medically necessary, arelisted in the plan’s Medical Benefits Chart (this chart is in Chapter 4 of this booklet), and areobtained consistent with plan rules. You are responsible for paying the full cost of services thataren’t covered by our plan, either because they are not plan covered services, or plan rules werenot followed.

If you have any questions about whether we will pay for any medical service or care that you areconsidering, you have the right to ask us whether we will cover it before you get it. You also havethe right to ask for this in writing. If we say we will not cover your services, you have the right toappeal our decision not to cover your care.

Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints))has more information about what to do if you want a coverage decision from us or want to appeala decision we have already made. You may also call Customer Service to get more information(phone numbers are printed on the back cover of this booklet).

For covered services that have a benefit limitation, you pay the full cost of any services you getafter you have used up your benefit for that type of covered service. When the benefit limit hasbeen reached, the costs you pay do not count toward your out-of-pocket maximum. You can callCustomer Service when you want to know how much of your benefit limit you have already used.

SECTION 5 How are your medical services covered when you are ina “clinical research study”?

Section 5.1 What is a “clinical research study”?

A clinical research study (also called a “clinical trial”) is a way that doctors and scientists test newtypes of medical care, like howwell a new cancer drug works. They test newmedical care proceduresor drugs by asking for volunteers to help with the study. This kind of study is one of the final stagesof a research process that helps doctors and scientists see if a new approach works and if it is safe.


Not all clinical research studies are open to members of our plan. Medicare first needs to approvethe research study. If you participate in a study that Medicare has not approved, you will beresponsible for paying all costs for your participation in the study.

Once Medicare approves the study, someone who works on the study will contact you to explainmore about the study and see if you meet the requirements set by the scientists who are runningthe study. You can participate in the study as long as you meet the requirements for the study andyou have a full understanding and acceptance of what is involved if you participate in the study.

If you participate in a Medicare-approved study, Original Medicare pays most of the costs for thecovered services you receive as part of the study. When you are in a clinical research study, youmay stay enrolled in our plan and continue to get the rest of your care (the care that is not relatedto the study) through our plan.

If you want to participate in a Medicare-approved clinical research study, you do not need to getapproval from us or your PCP. The providers that deliver your care as part of the clinical researchstudy do not need to be part of our plan’s network of providers.

Although you do not need to get our plan’s permission to be in a clinical research study, you doneed to tell us before you start participating in a clinical research study. Here is why you needto tell us:

1. We can let you know whether the clinical research study is Medicare-approved.

2. We can tell you what services you will get from clinical research study providers instead offrom our plan.

If you plan on participating in a clinical research study, contact Customer Service (phone numbersare printed on the back cover of this booklet).

Section 5.2 When you participate in a clinical research study, who pays forwhat?

Once you join a Medicare-approved clinical research study, you are covered for routine items andservices you receive as part of the study, including:

1 Room and board for a hospital stay that Medicare would pay for even if you weren’t in astudy.

1 An operation or other medical procedure if it is part of the research study.

1 Treatment of side effects and complications of the new care.

Original Medicare pays most of the cost of the covered services you receive as part of the study.After Medicare has paid its share of the cost for these services, our plan will also pay for part ofthe costs. We will pay the difference between the cost-sharing in Original Medicare and yourcost-sharing as a member of our plan. This means you will pay the same amount for the servicesyou receive as part of the study as you would if you received these services from our plan.


Here’s an example of how the cost-sharing works: Let’s say that you have a lab test that costs$100 as part of the research study. Let’s also say that your share of the costs for this test is $20under Original Medicare, but the test would be $10 under our plan’s benefits. In this case,Original Medicare would pay $80 for the test and we would pay another $10. This means thatyou would pay $10, which is the same amount you would pay under our plan’s benefits.

In order for us to pay for our share of the costs, you will need to submit a request for payment. Withyour request, you will need to send us a copy of your Medicare Summary Notices or otherdocumentation that shows what services you received as part of the study and how much you owe.Please see Chapter 7 for more information about submitting requests for payment.

When you are part of a clinical research study, neither Medicare nor our plan will pay for anyof the following:

1 Generally, Medicare will not pay for the new item or service that the study is testing unlessMedicare would cover the item or service even if you were not in a study.

1 Items and services the study gives you or any participant for free.

1 Items or services provided only to collect data, and not used in your direct health care. Forexample, Medicare would not pay for monthly CT scans done as part of the study if yourmedical condition would normally require only one CT scan.

Do you want to know more?You can get more information about joining a clinical research study by reading the publication“Medicare and Clinical Research Studies” on the Medicare website (http://www.medicare.gov).You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDDusers should call 1-877-486-2048.

SECTION 6 Rules for getting care covered in a “religious non-medicalhealth care institution”

Section 6.1 What is a religious non-medical health care institution?

A religious non-medical health care institution is a facility that provides care for a condition thatwould ordinarily be treated in a hospital or skilled nursing facility care. If getting care in a hospitalor a skilled nursing facility is against a member’s religious beliefs, we will instead provide coveragefor care in a religious non-medical health care institution. You may choose to pursue medical careat any time for any reason. This benefit is provided only for Part A inpatient services (non-medicalhealth care services). Medicare will only pay for non-medical health care services provided byreligious non-medical health care institutions.


Section 6.2 What care from a religious non-medical health care institution iscovered by our plan?

To get care from a religious non-medical health care institution, you must sign a legal documentthat says you are conscientiously opposed to getting medical treatment that is “non-excepted.”

1 “Non-excepted” medical care or treatment is any medical care or treatment that is voluntaryand not required by any federal, state, or local law.

1 “Excepted” medical treatment is medical care or treatment that you get that is not voluntaryor is required under federal, state, or local law.

To be covered by our plan, the care you get from a religious non-medical health care institutionmust meet the following conditions:

1 The facility providing the care must be certified by Medicare.

1 Our plan’s coverage of services you receive is limited to non-religious aspects of care.

1 If you get services from this institution that are provided to you in your home, our plan willcover these services only if your condition would ordinarily meet the conditions for coverageof services given by home health agencies that are not religious non-medical health careinstitutions.

1 If you get services from this institution that are provided to you in a facility, the followingconditions apply:

4 You must have a medical condition that would allow you to receive covered services forinpatient hospital care or skilled nursing facility care.

4 – and – you must get approval in advance from our plan before you are admitted to thefacility or your stay will not be covered.

The plan inpatient hospital coverage limits apply to care received in a religious non-medical healthcare institution. For more information, see the Medical Benefits Chart in Chapter 4.

SECTION 7 Rules for ownership of durable medical equipment

Section 7.1 Will you own the durable medical equipment after making a certainnumber of payments under our plan?

Durable medical equipment includes items such as oxygen equipment and supplies, wheelchairs,walkers, and hospital beds ordered by a provider for use in the home. Certain items, such asprosthetics, are always owned by the member. In this section, we discuss other types of durablemedical equipment that must be rented.

In OriginalMedicare, people who rent certain types of durablemedical equipment own the equipmentafter paying copayments for the item for 13months. As a member ofMemorial Hermann AdvantagePPO, however, you usually will not acquire ownership of rented durable medical equipment items


no matter how many copayments you make for the item while a member of our plan. Under certainlimited circumstances we will transfer ownership of the durable medical equipment item. CallCustomer Service (phone numbers are printed on the back cover of this booklet) to find out aboutthe requirements you must meet and the documentation you need to provide.

What happens to payments you have made for durable medical equipment if youswitch to Original Medicare?If you switch to OriginalMedicare after being amember of our plan: If you did not acquire ownershipof the durable medical equipment itemwhile in our plan, you will have to make 13 new consecutivepayments for the item while in Original Medicare in order to acquire ownership of the item. Yourprevious payments while in our plan do not count toward these 13 consecutive payments.

If you made payments for the durable medical equipment item under Original Medicare before youjoined our plan, these previous Original Medicare payments also do not count toward the 13consecutive payments. You will have to make 13 consecutive payments for the item under OriginalMedicare in order to acquire ownership. There are no exceptions to this case when you return toOriginal Medicare.


CHAPTER 4Medical Benefits Chart(what is covered and

what you pay)

Chapter 4. Medical Benefits Chart (what is covered and what you pay)

SECTION 1 Understanding your out-of-pocket costs for covered services ...... 50

Section 1.1 Types of out-of-pocket costs you may pay for your covered services ........... 50

Section 1.2 What is the most you will pay for Medicare Part A and Part B coveredmedical services? ............................................................................................ 50

Section 1.3 Our plan does not allow providers to “balance bill” you ............................... 51

SECTION 2 Use theMedical Benefits Chart to find out what is covered for youand how much you will pay ................................................................52

Section 2.1 Your medical benefits and costs as a member of the plan .............................. 52

Section 2.2 Extra “optional supplemental” benefits you can buy ..................................... 82

SECTION 3 What services are not covered by the plan? ..................................... 85

Section 3.1 Services we do not cover (exclusions) ........................................................... 85

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 49Chapter 4. Medical Benefits Chart (what is covered and what you pay)

SECTION 1 Understanding your out-of-pocket costs for coveredservices

This chapter focuses on your covered services and what you pay for your medical benefits. Itincludes a Medical Benefits Chart that lists your covered services and shows how much you willpay for each covered service as a member of Memorial Hermann Advantage PPO. Later in thischapter, you can find information about medical services that are not covered. It also explains limitson certain services.

Section 1.1 Types of out-of-pocket costs youmay pay for your covered services

To understand the payment information we give you in this chapter, you need to know about thetypes of out-of-pocket costs you may pay for your covered services.

1 A “copayment” is the fixed amount you pay each time you receive certain medical services.You pay a copayment at the time you get the medical service. (The Medical Benefits Chartin Section 2 tells you more about your copayments.)

1 “Coinsurance” is the percentage you pay of the total cost of certain medical services. Youpay a coinsurance at the time you get the medical service. (The Medical Benefits Chart inSection 2 tells you more about your coinsurance.)

Some people qualify for State Medicaid programs to help them pay their out-of-pocket costs forMedicare. (These “Medicare Savings Programs” include the QualifiedMedicare Beneficiary (QMB),Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and QualifiedDisabled &Working Individuals (QDWI) programs.) If you are enrolled in one of these programs,you may still have to pay a copayment for the service, depending on the rules in your state.

Section 1.2 What is the most you will pay for Medicare Part A and PartB covered medical services?

Under our plan, there are two different limits on what you have to pay out-of-pocket for coveredmedical services:

1 Your in-network maximum out-of-pocket amount is $6,700.00. This is the most you payduring the calendar year for covered Medicare Part A and Part B services received fromnetwork providers. The amounts you pay for copayments and coinsurance for covered servicesfrom network providers count toward this in-network maximum out-of-pocket amount. (Theamounts you pay for your Part D prescription drugs, and services from out-of-networkproviders do not count toward your in-network maximum out-of-pocket amount). If you havepaid $6,700.00 for covered Part A and Part B services from network providers, you will nothave any out-of-pocket costs for the rest of the year when you see our network providers.However, you must continue to pay the Medicare Part B premium (unless your Part Bpremium is paid for you by Medicaid or another third party).


1 Your combined maximum out-of-pocket amount is $7,000.00. This is the most you payduring the calendar year for covered Medicare Part A and Part B services received from bothin-network and out-of-network providers. The amounts you pay for copayments andcoinsurance for covered services count toward this combinedmaximumout-of-pocket amount.(The amounts you pay for your Part D prescription drugs do not count toward your combinedmaximum out-of-pocket amount. In addition, amounts you pay for some services do notcount toward your combined maximum out-of-pocket amount. These services are marked inthe Medical Benefits Chart.) If you have paid $7,000.00 for covered services, you will have100% coverage and will not have any out-of-pocket costs for the rest of the year for coveredPart A and Part B services. However, you must continue to pay theMedicare Part B premium(unless your Part B premium is paid for you by Medicaid or another third party).

Section 1.3 Our plan does not allow providers to “balance bill” you

As a member of Memorial Hermann Advantage PPO, an important protection for you is that youonly have to pay your cost-sharing amount when you get services covered by our plan. We do notallow providers to add additional separate charges, called “balance billing.” This protection (thatyou never pay more than your cost-sharing amount) applies even if we pay the provider less thanthe provider charges for a service and even if there is a dispute and we don’t pay certain providercharges.

Here is how this protection works.

1 If your cost-sharing is a copayment (a set amount of dollars, for example, $15.00), then youpay only that amount for any covered services from a network provider. You will generallyhave higher copays when you obtain care from out-of-network providers.

1 If your cost-sharing is a coinsurance (a percentage of the total charges), then you never paymore than that percentage. However, your cost depends on which type of provider you see:

4 If you obtain covered services from a network provider, you pay the coinsurance percentagemultiplied by the plan’s reimbursement rate (as determined in the contract between theprovider and the plan).

4 If you obtain covered services from an out-of-network provider who participates withMedicare, you pay the coinsurance percentage multiplied by the Medicare payment ratefor participating providers.

4 If you obtain covered services from an out-of-network provider who does not participatewithMedicare, then you pay the coinsurance amount multiplied by theMedicare paymentrate for non-participating providers.

1 If you believe a provider has “balance billed” you, call Customer Service (phone numbersare printed on the back cover of this booklet).


SECTION 2 Use theMedical Benefits Chart to find out what is coveredfor you and how much you will pay

Section 2.1 Your medical benefits and costs as a member of the plan

TheMedical Benefits Chart on the following pages lists the servicesMemorial Hermann AdvantagePPO covers and what you pay out-of-pocket for each service. The services listed in the MedicalBenefits Chart are covered only when the following coverage requirements are met:

1 Your Medicare covered services must be provided according to the coverage guidelinesestablished by Medicare.

1 Your services (including medical care, services, supplies, and equipment)must be medicallynecessary. “Medically necessary” means that the services, supplies, or drugs are needed forthe prevention, diagnosis, or treatment of your medical condition andmeet accepted standardsof medical practice.

1 Some of the services listed in the Medical Benefits Chart are covered as in-network servicesonly if your doctor or other network provider gets approval in advance (sometimes called“prior authorization”) from Memorial Hermann Advantage PPO.

4 Covered services that need approval in advance to be covered as in-network services aremarked by an asterisk in the Medical Benefits Chart.

4 You never need approval in advance for out-of-network services from out-of-networkproviders.

4 While you don’t need approval in advance for out-of-network services, you or your doctorcan ask us to make a coverage decision in advance.

Other important things to know about our coverage:

1 For benefits where your cost-sharing is a coinsurance percentage, the amount you pay dependson what type of provider you receive the services from:

4 If you receive the covered services from a network provider, you pay the coinsurancepercentage multiplied by the plan’s reimbursement rate (as determined in the contractbetween the provider and the plan)

4 If you receive the covered services from an out-of-network provider who participates withMedicare, you pay the coinsurance percentage multiplied by the Medicare payment ratefor participating providers,

4 If you receive the covered services from an out-of-network provider who does notparticipate withMedicare, you pay the coinsurance percentage multiplied by theMedicarepayment rate for non-participating providers.


1 Like all Medicare health plans, we cover everything that Original Medicare covers. For someof these benefits, you pay more in our plan than you would in Original Medicare. For others,you pay less. (If you want to know more about the coverage and costs of Original Medicare,look in yourMedicare & You 2016Handbook. View it online at http://www.medicare.gov orask for a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days aweek. TTY/TDD users should call 1-877-486-2048.)

1 For all preventive services that are covered at no cost under OriginalMedicare, we also coverthe service at no cost to you. However, if you also are treated or monitored for an existingmedical condition during the visit when you receive the preventive service, a copayment willapply for the care received for the existing medical condition.

1 Sometimes, Medicare adds coverage under Original Medicare for new services during theyear. If Medicare adds coverage for any services during 2016, either Medicare or our planwill cover those services.

You will see this apple next to the preventive services in the benefits chart.

Medical Benefits Chart

What you must pay when you get theseservices

Services that are covered for you

In-NetworkAbdominal aortic aneurysm screening

A one-time screening ultrasound for people atrisk. The plan only covers this screening if you

There is no coinsurance, copayment, ordeductible for beneficiaries eligible for thispreventive screening.

have certain risk factors and if you get a referral Out-of-Networkfor it from your physician, physician assistant,nurse practitioner, or clinical nurse specialist. 40% of the cost for Medicare-covered screening

ultrasound for abdominal aortic aneurysm.

If your provider performs additional diagnosticor surgical procedures, or if other medicalservices are provided for othermedical conditionsduring the same visit, then the appropriate costshare applies for those services rendered duringthat visit.

In-NetworkAmbulance services

$250.00 copay forMedicare-covered ambulanceservices per one-way trip.




Out-of-Network1 Covered ambulance services include fixedwing, rotary wing, and ground ambulanceservices, to the nearest appropriate facilitythat can provide care only if they are furnishedto a member whose medical condition is suchthat other means of transportation couldendanger the person’s health or if authorizedby the plan.

$250.00 copay forMedicare-covered ambulanceservices per one-way trip.

*Non-emergent transportation prior authorizationrequired

1 Non-emergency transportation by ambulanceis appropriate if it is documented that themember’s condition is such that other meansof transportation could endanger the person’shealth and that transportation by ambulanceis medically required.

In-NetworkAnnual wellness visit

If you’ve had Part B for longer than 12 months,you can get an annual wellness visit to develop

There is no coinsurance, copayment, ordeductible for the annual wellness visit.

Out-of-Networkor update a personalized prevention plan based

40% of the cost for Medicare-covered annualwellness visit.

on your current health and risk factors. This iscovered once every 12 months.

If your provider performs additional diagnosticor surgical procedures, or if other medical

Note: Your first annual wellness visit can’t takeplace within 12 months of your “Welcome to

services are provided for othermedical conditionsMedicare” preventive visit. However, you don’tduring the same visit, then the appropriate costneed to have had a “Welcome to Medicare” visitshare applies for those services rendered duringthat visit.

to be covered for annual wellness visits afteryou’ve had Part B for 12 months.

In-NetworkBone mass measurement

For qualified individuals (generally, this meanspeople at risk of losing bone mass or at risk of

There is no coinsurance, copayment, ordeductible for Medicare-covered bone massmeasurement.

osteoporosis), the following services are covered Out-of-Networkevery 24 months or more frequently if medically

40% of the cost forMedicare-covered bone massmeasurement.

necessary: procedures to identify bone mass,detect bone loss, or determine bone quality,including a physician’s interpretation of theresults.





services are provided for othermedical conditionsduring the same visit, then the appropriate costshare applies for those services rendered duringthat visit.

In-NetworkBreast cancer screening (mammograms)

Covered services include:There is no coinsurance, copayment, ordeductible for covered screening mammograms.

Out-of-Network1 One baseline mammogram between the agesof 35 and 39 40% of the cost for Medicare-covered Breast

cancer screening (mammograms).1 One screeningmammogram every 12monthsfor women age 40 and older If your provider performs additional diagnostic

or surgical procedures, or if other medical1 Clinical breast exams once every 24 monthsservices are provided for othermedical conditionsduring the same visit, then the appropriate costshare applies for those services rendered duringthat visit.

In-NetworkCardiac rehabilitation services

*$0.00 copay for Medicare-covered CardiacRehabilitation Services.

Comprehensive programs of cardiacrehabilitation services that include exercise,education, and counseling are covered for Out-of-Networkmembers who meet certain conditions with a

40% of the cost for Medicare-covered CardiacRehabilitation Services.

doctor’s order. The plan also covers intensivecardiac rehabilitation programs that are typicallymore rigorous or more intense than cardiacrehabilitation programs.

In-NetworkCardiovascular disease risk reduction

visit (therapy for cardiovascular disease)

We cover one visit per year with your primarycare doctor to help lower your risk for

There is no coinsurance, copayment, ordeductible for the intensive behavioral therapycardiovascular disease preventive benefit.

Out-of-Networkcardiovascular disease. During this visit, your

40% of the cost Medicare-covered intensivetherapy to reduce the risk of cardiovasculardisease.

doctor may discuss aspirin use (if appropriate),check your blood pressure, and give you tips tomake sure you’re eating well.





In-NetworkCardiovascular disease testing

Blood tests for the detection of cardiovasculardisease (or abnormalities associated with an

There is no coinsurance, copayment, ordeductible for cardiovascular disease testing thatis covered once every 5 years.

elevated risk of cardiovascular disease) onceevery 5 years (60 months).

Out-of-Network

40% of the cost for Medicare-coveredcardiovascular screening blood test.


In-NetworkCervical and vaginal cancer screening

Covered services include:There is no coinsurance, copayment, ordeductible for Medicare-covered preventive Papand pelvic exams.

1 For all women: Pap tests and pelvic examsare covered once every 24 months Out-of-Network

40% of the cost for Medicare-covered Cervicaland vaginal cancer screening.

1 If you are at high risk of cervical cancer orhave had an abnormal Pap test and are ofchildbearing age: one Pap test every 12months


In-NetworkChiropractic services

$20.00 copay for eachMedicare-covered service.Covered services include:




Out-of-Network1 We cover only Manual manipulation ofthe spine to correct subluxation 40% of the cost for each Medicare-covered

service.

Colorectal cancer screening

For people 50 and older, the following arecovered:

In-Network

There is no coinsurance, copayment, ordeductible for a Medicare-covered colorectalcancer screening exam.1 Flexible sigmoidoscopy (or screening

barium enema as an alternative) every 48months

Out-of-Network

40% of the cost forMedicare-covered Colorectalcancer screenings.1 Fecal occult blood test, every 12 months

For people at high risk of colorectal cancer, wecover:

If your provider performs additional diagnosticor surgical procedures, or if other medicalservices are provided for othermedical conditions1 Screening colonoscopy (or screening

barium enema as an alternative) every 24months

during the same visit, then the appropriate costshare applies for those services rendered duringthat visit.For people not at high risk of colorectal cancer,

we cover:

1 Screening colonoscopy every 10 years(120 months), but not within 48 months ofa screening sigmoidoscopy

In-NetworkDental services

Preventive Services are not covered underMemorial Hermann Advantage (PPO).

In general, preventive dental services (such ascleaning, routine dental exams, and dental x-rays)are not covered by OriginalMedicare.We cover: *Medicare Covered Comprehensive Services are

covered only following reconstruction of the jaw,Medicare-covered dental services limited tosurgery of the jaw or facial bones, extraction of accidental injury or extractions in preparation for

radiation treatment.$75.00 copay for Medicare CoveredComprehensive Services performed byPCP/Specialist.$75.00 copay for Comprehensive Servicesperformed in an Emergency setting.

teeth to prepare the jaw for radiation treatmentsof neoplastic cancer disease, or services thatwould be covered when provided by a physician.




Out-of-Network

40% of the cost for Medicare-covered dentalservices.

In-NetworkDepression screening

We cover one screening for depression per year.The screening must be done in a primary care

There is no coinsurance, copayment, ordeductible for an annual depression screeningvisit.

setting that can provide follow-up treatment andreferrals.

Out-of-Network

40% of the cost forMedicare-coveredDepressionscreening.


In-NetworkDiabetes screening

We cover this screening (includes fasting glucosetests) if you have any of the following risk

There is no coinsurance, copayment, ordeductible for the Medicare covered diabetesscreening tests.

factors: high blood pressure (hypertension), Out-of-Networkhistory of abnormal cholesterol and triglyceride

40% of the cost for Medicare-covered Diabetesscreenings.

levels (dyslipidemia), obesity, or a history of highblood sugar (glucose). Tests may also be coveredif you meet other requirements, like being If your provider performs additional diagnostic

or surgical procedures, or if other medicaloverweight and having a family history ofdiabetes. services are provided for othermedical conditions

during the same visit, then the appropriate costBased on the results of these tests, you may beeligible for up to two diabetes screenings every12 months.

share applies for those services rendered duringthat visit.




In-NetworkDiabetes self-management training,

diabetic services and supplies

For all people who have diabetes (insulin andnon-insulin users). Covered services include:

$0.00 of the cost for Medicare-covered Diabetesmonitoring supplies.

$0.00 copay for Medicare-covered Diabetesself-management training.

1 Supplies to monitor your blood glucose:Blood glucose monitor, blood glucose teststrips, lancet devices and lancets, andglucose-control solutions for checking theaccuracy of test strips and monitors.

$0.00 copay for Medicare-covered Therapeuticshoes or inserts.

Out-of-Network1 For people with diabetes who have severediabetic foot disease: One pair per calendaryear of therapeutic custom-molded shoes(including inserts provided with such shoes)and two additional pairs of inserts, or one pairof depth shoes and three pairs of inserts (notincluding the non-customized removableinserts provided with such shoes). Coverageincludes fitting.

40% of the cost for Medicare-covered Diabetesmonitoring supplies.

40% of the cost for Medicare-covered Diabetesself-management training.

40% of the cost for Medicare-coveredTherapeutic shoes or inserts.

One routine foot exam covered every six months.

If your provider performs additional diagnosticor surgical procedures, or if other medical1 Diabetes self-management training is covered

under certain conditions. services are provided for othermedical conditionsduring the same visit, then the appropriate costshare applies for those services rendered duringthat visit.

In-NetworkDurable medical equipment and relatedsupplies *20% of the cost for Medicare-covered durable

medical equipment.(For a definition of “durablemedical equipment,”see Chapter 12 of this booklet.) 20% of the cost of Medicare-covered Part B

drugs including allergy injections.Covered items include, but are not limited to:wheelchairs, crutches, hospital bed, IV infusionpump, oxygen equipment, nebulizer, and walker. Out-of-NetworkWe cover all medically necessary durablemedical equipment covered by Original

40% of the cost for Medicare-covered durablemedical equipment.

Medicare. If our supplier in your area does not40% of the cost of Medicare-covered Part Bdrugs including allergy injections.

carry a particular brand or manufacturer, youmay ask them if they can special order it for you.

In-NetworkEmergency care




$75.00 copay for each Medicare-coveredemergency room visit.

Emergency care refers to services that are:

1 Furnished by a provider qualified to furnishemergency services, and $75.00 copay for worldwide emergency services.

1 Needed to evaluate or stabilize an emergencymedical condition. Out-of-Network

A medical emergency is when you, or any otherprudent layperson with an average knowledge of

$75.00 copay for each Medicare-coveredemergency room visit.

health and medicine, believe that you have$75.00 copay for worldwide emergency services.medical symptoms that require immediate

medical attention to prevent loss of life, loss of If you receive emergency care at anout-of-network hospital and need inpatient carea limb, or loss of function of a limb. The medical

symptoms may be an illness, injury, severe pain, after your emergency condition is stabilized, youor a medical condition that is quickly gettingworse.

must move to a network hospital in order to paythe in-network cost-sharing amount for the partof your stay after you are stabilized. If you stayThis coverage is world-wide.at the out-of-network hospital, your stay will becovered but you will pay the out-of-networkcost-sharing amount for the part of your stay afteryou are stabilized.

In-NetworkHealth andwellness education programs

Includes 24/7 Nursing Hotline and FitnessProgram.

$0.00 copay for Fitness program at your localcontracted Facility.

$0.00 copay for 24/7 nurse line servicesperformed by the contracted vendor as a part ofthe wellness benefit.

1 24/7 Nurseline:Our plan offers Nurse triage 24 hours, 7days aweek

1 Fitness Center Membership:Out-of-Network

$0.00 copay for fitness program via home

exercise kit program.New and fun ways to get fit and stay healthy, the Silver&Fit program consists of:

$0.00 copay for 24/7 nurse line services through the dedicated nurse line toll free telephone number.

1 Being a member at a Silver&Fit fitnessclub or exercise center that participates inthe Memorial Hermann Advantage PPObasic program is at no cost to you. Youmay choose to purchase additional buy-upservices. Contact your exercise center.




1 The Silver&Fit Home Fitness program ifyou cannot get to a fitness facility or preferto work out at home

1 Healthy Aging classes (online or DVD)

1 The Silver Slate® newsletter 4 times a year

1 The Silver&Fit website

1 A toll-free telephone hotline to answerquestions about the program

Available contracted fitness club location mustbe utilized throughout the service area. Specificclass offerings will vary by location.

In-NetworkHearing services

$40.00 copay for annual hearing exam.$500 plan maximum benefit every two years foreither one or two ears.

Diagnostic hearing and balance evaluationsperformed by your provider to determine if youneed medical treatment are covered as outpatientcare when furnished by a physician, audiologist,or other qualified provider.

$0.00 copay for each Medicare-covered basichearing and balance exam performed by aprimary care doctor.

$40.00 copay for each Medicare-covered basichearing and balance exam performed by aspecialist, audiologist or other provider that isnot a primary care doctor.

Out-of-Network

40% of the cost for annual hearing exam.$500 plan maximum benefit every two years foreither one or two ears.

40% of the cost for eachMedicare-covered basichearing and balance exam performed by aprimary care doctor.

40% of the cost for eachMedicare-covered basichearing and balance exam performed by aspecialist, audiologist or other provider that isnot a primary care doctor.




In-NetworkHIV screening

For people who ask for an HIV screening test orwho are at increased risk for HIV infection, wecover:

There is no coinsurance, copayment, ordeductible for beneficiaries eligible forMedicare-covered preventive HIV screening.

1 One screening exam every 12 months Out-of-NetworkFor women who are pregnant, we cover: 40% of the cost for Medicare-covered HIV

screenings.1 Up to three screening exams during apregnancy

In-NetworkHome health agency care

*$0.00 copay for each Medicare-covered homehealth visit.

Prior to receiving home health services, a doctormust certify that you need home health servicesand will order home health services to beprovided by a home health agency. You must be

Out-of-Networkhomebound, which means leaving home is amajor effort. 40% of the cost for eachMedicare-covered home

health visit.Covered services include, but are not limited to:

1 Part-time or intermittent skilled nursing andhome health aide services (To be coveredunder the home health care benefit, yourskilled nursing and home health aide servicescombined must total fewer than 8 hours perday and 35 hours per week)

1 Physical therapy, occupational therapy, andspeech therapy

1 Medical and social services

1 Medical equipment and supplies

When you enroll in aMedicare-certified hospiceprogram, your hospice services and your Part A

Hospice care

You may receive care from anyMedicare-certified hospice program. You are and Part B services related to your terminal

prognosis are paid for by Original Medicare,not Memorial Hermann Advantage PPO

eligible for the hospice benefit when your doctorand the hospice medical director have given youa terminal prognosis certifying that you’reterminally ill and have 6 months or less to live




if your illness runs its normal course. Yourhospice doctor can be a network provider or anout-of-network provider.

Covered services include:

1 Drugs for symptom control and pain relief

1 Short-term respite care

1 Home care

For hospice services and for services that arecovered by Medicare Part A or B and are relatedto your terminal prognosis: Original Medicare(rather than our plan) will pay for your hospiceservices and any Part A and Part B servicesrelated to your terminal prognosis. While youare in the hospice program, your hospice providerwill bill Original Medicare for the services thatOriginal Medicare pays for.

For services that are covered byMedicare Part Aor B and are not related to your terminalprognosis: If you need non-emergency,non-urgently needed services that are coveredunder Medicare Part A or B and that are notrelated to your terminal prognosis, your cost forthese services depends on whether you use aprovider in our plan’s network:

1 If you obtain the covered services from anetwork provider, you only pay the plancost-sharing amount for in-network services

1 If you obtain the covered services from anout-of-network provider, you pay the plancost-sharing for out-of-network services

For services that are covered by MemorialHermann Advantage PPO but are not coveredby Medicare Part A or B:Memorial HermannAdvantage PPO will continue to coverplan-covered services that are not covered underPart A or B whether or not they are related to




your terminal prognosis. You pay your plancost-sharing amount for these services.

For drugs that may be covered by the plan’sPart D benefit: Drugs are never covered by bothhospice and our plan at the same time. For moreinformation, please see Chapter 5, Section 9.4(What if you’re in Medicare-certified hospice).

Note: If you need non-hospice care (care that isnot related to your terminal prognosis), youshould contact us to arrange the services. Gettingyour non-hospice care through our networkproviders will lower your share of the costs forthe services.

In-NetworkImmunizations

Covered Medicare Part B services include:There is no coinsurance, copayment, ordeductible for the pneumonia, influenza, andHepatitis B vaccines.

1 Pneumonia vaccine

1 Flu shots, once a year in the fall or winterOut-of-Network

1 Hepatitis B vaccine if you are at high orintermediate risk of getting Hepatitis B 40% of the cost for Medicare-covered

pneumonia, influenza and Hepatits B vaccines.1 Other vaccines if you are at risk and theymeetMedicare Part B coverage rules

Other Part BMedicare-covered vaccines if a riskis present.

We also cover some vaccines under our Part Dprescription drug benefit.

If your provider performs additional diagnosticor surgical procedures, or if other medicalservices are provided for othermedical conditionsduring the same visit, then the appropriate costshare applies for those services rendered duringthat visit

In-NetworkInpatient hospital care

*For each Medicare-covered hospital stay:Days 1 - 5: $250.00 copay per day.Days 6 - 90: $0.00 copay per day.

Includes inpatient acute, inpatient rehabilitation,long-term care hospitals and other types ofinpatient hospital services. Inpatient hospital carestarts the day you are formally admitted to the




Out-of-Networkhospital with a doctor’s order. The day beforeyou are discharged is your last inpatient day. 40% of the cost for each Medicare-covered

hospital stay.Unlimited days per benefit period.

Covered services include but are not limited to:

1 Semi-private room (or a private room ifmedically necessary)

1 Meals including special diets

1 Regular nursing services

1 Costs of special care units (such asintensive care or coronary care units)

1 Drugs and medications

1 Lab tests

1 X-rays and other radiology services

1 Necessary surgical and medical supplies

1 Use of appliances, such as wheelchairs

1 Operating and recovery room costs

1 Physical, occupational, and speechlanguage therapy

1 Inpatient substance abuse services

Under certain conditions, the following types oftransplants are covered: corneal, kidney,kidney-pancreatic, heart, liver, lung, heart/lung,bone marrow, stem cell, and intestinal/multivisceral. If you need a transplant, we willarrange to have your case reviewed by aMedicare-approved transplant center that willdecide whether you are a candidate for atransplant. Transplant providers may be local oroutside of the service area. If our in-networktransplant services are at a distant location, youmay choose to go locally or distant as long as thelocal transplant providers are willing to acceptthe Original Medicare rate.




If you get authorized inpatient care at anout-of-network hospital after your emergency

Inpatient hospital care (continued)

If Memorial Hermann Advantage PPO providestransplant services at a distant location (outside condition is stabilized, your cost is the

cost-sharing youwould pay at a network hospital.of the service area) and you chose to obtaintransplants at this distant location, we willarrange or pay for appropriate lodging andtransportation costs for you and a companion.The plan will cover travel costs consistent withIRS travel mileage and lodging guidelines, notto exceed $100 per day per covered room.

1 Blood - including storage andadministration. Coverage of whole bloodand packed red cells begins only with thefourth pint of blood that you need - youmust either pay the costs for the first 3pints of blood you get in a calendar yearor have the blood donated by you orsomeone else. All other components ofblood are covered beginning with the firstpint used.

1 Physician services

Note: To be an inpatient, your provider mustwrite an order to admit you formally as aninpatient of the hospital. Even if you stay in thehospital overnight, you might still be consideredan “outpatient.” If you are not sure if you are aninpatient or an outpatient, you should ask thehospital staff.

You can also find more information in aMedicare fact sheet called “Are You a HospitalInpatient or Outpatient? If You Have Medicare– Ask!” This fact sheet is available on the Webathttp://www.medicare.gov/Publications/Pubs/pdf/11435.pdfor by calling 1-800-MEDICARE(1-800-633-4227). TTY/TDD users call1-877-486-2048. You can call these numbers forfree, 24 hours a day, 7 days a week.




In-NetworkInpatient mental health care

*For each Medicare-covered hospital stay:Days 1 - 5: $250.00 copay per dayDays 6 - 90: $0.00 copay per day.

Covered services include mental health careservices that require a hospital stay.

Our plan covers an unlimited number of days foran inpatient hospital stay.

Out-of-Network

40% of the cost for each Medicare-coveredhospital stay.

You pay 100% of facility charges for anon-covered inpatient stay.

Inpatient services covered during anon-covered inpatient stay

Your applicable outpatient services copaymentsand/or coinsurances apply to the

If you have exhausted your inpatient benefits orif the inpatient stay is not reasonable and

Medicare-Covered Services and supplies youreceive during a non-covered SNF stay.

necessary, we will not cover your inpatient stay.However, in some cases, we will cover certainservices you receive while you are in the hospital Please see outpatient services below for your

costs.or the skilled nursing facility (SNF). Coveredservices include, but are not limited to:

1 Physician services

1 Diagnostic tests (like lab tests)

1 X-ray, radium, and isotope therapy includingtechnician materials and services

1 Surgical dressings

1 Splints, casts and other devices used to reducefractures and dislocations

1 Prosthetics and orthotics devices (other thandental) that replace all or part of an internalbody organ (including contiguous tissue), orall or part of the function of a permanentlyinoperative or malfunctioning internal bodyorgan, including replacement or repairs ofsuch devices




1 Leg, arm, back, and neck braces; trusses, andartificial legs, arms, and eyes includingadjustments, repairs, and replacementsrequired because of breakage, wear, loss, ora change in the patient’s physical condition

1 Physical therapy, speech therapy, andoccupational therapy

In-NetworkLong Term Acute Care (LTAC)

If the admission occurs as result of transfer fromacute, the copay is waived. If the admission is a

A long term acute care facility is a specialty-carehospital designed for patients with serious

direct admit the copay is the Inpatient HospitalStay copayment:

medical problems that require intense, specialtreatment for an extended period of time—usually20 to 30 days. *For each Medicare-covered hospital stay:

Days 1 - 5: $250.00 copay per day.Days 6 - 90: $0.00 copay per day.

Out-of-Network

40% of the cost for each Medicare-coveredhospital stay.

Medical nutrition therapy

This benefit is for people with diabetes, renal(kidney) disease (but not on dialysis), or after akidney transplant when ordered by your doctor.

In-Network

There is no coinsurance, copayment, ordeductible for beneficiaries eligible forMedicare-covered medical nutrition therapyservices.We cover 3 hours of one-on-one counseling

services during your first year that you receive Out-of-Networkmedical nutrition therapy services under

40% of the cost for Medicare-covered medicalnutritional therapy services.

Medicare (this includes our plan, any otherMedicare Advantage plan, or OriginalMedicare),and 2 hours each year after that. If your If your provider performs additional diagnostic

or surgical procedures, or if other medicalcondition, treatment, or diagnosis changes, youmay be able to receive more hours of treatment services are provided for othermedical conditionswith a physician’s order. A physician must during the same visit, then the appropriate costprescribe these services and renew their order share applies for those services rendered during

that visit.yearly if your treatment is needed into the nextcalendar year.




In-NetworkMedicare Part B prescription drugs

20% of the cost for Part B-coveredDrugs coveredunder Medicare Part B (Original Medicare).

These drugs are covered under Part B of OriginalMedicare.Members of our plan receive coveragefor these drugs through our plan. Covered drugsinclude:

20% of the cost for Part B-covered chemotherapydrugs.

1 Drugs that usually aren’t self-administeredby the patient and are injected or infusedwhile you are getting physician, hospitaloutpatient, or ambulatory surgical centerservices

20% of the cost of Medicare-covered Part Bdrugs including allergy injections.

Out-of-Network

40% of the cost for Part B-coveredDrugs coveredunder Medicare Part B (Original Medicare).1 Drugs you take using durable medical

equipment (such as nebulizers) that wereauthorized by the plan

40% of the cost for Part B-covered chemotherapydrugs.

1 Clotting factors you give yourself byinjection if you have hemophilia

40% of the cost of Medicare-covered Part Bdrugs including allergy injections.

1 Immunosuppressive Drugs, if you wereenrolled in Medicare Part A at the time ofthe organ transplant

1 Injectable osteoporosis drugs, if you arehomebound, have a bone fracture that adoctor certifies was related topost-menopausal osteoporosis, and cannotself-administer the drug

1 Antigens

1 Certain oral anti-cancer drugs andanti-nausea drugs

1 Certain drugs for home dialysis, includingheparin, the antidote for heparin whenmedically necessary, topical anesthetics,and erythropoiesis-stimulating agents (suchas Epogen®, Procrit®, Epoetin Alfa,Aranesp®, or Darbepoetin Alfa)

1 Intravenous Immune Globulin for thehome treatment of primary immunedeficiency diseases




Chapter 5 explains the Part D prescription drugbenefit, including rules you must follow to haveprescriptions covered. What you pay for yourPart D prescription drugs through our plan isexplained in Chapter 6.

In-NetworkObesity screening and therapy to

promote sustained weight loss

If you have a body mass index of 30 or more, wecover intensive counseling to help you lose

There is no coinsurance, copayment, ordeductible for preventive obesity screening andtherapy.

weight. This counseling is covered if you get itOut-of-Networkin a primary care setting, where it can be

coordinated with your comprehensive prevention 40% of the cost for Medicare-covered Obesityscreening and therapy to promote sustainedweight loss.

plan. Talk to your primary care doctor orpractitioner to find out more.


In-NetworkOutpatient diagnostic tests and therapeuticservices and supplies $0.00 copay for Medicare-covered blood

services.Covered services include, but are not limited to:

*$0.00 copay for Medicare-coverednon-radiologic diagnostic procedures and tests.

1 X-rays

1 Radiation (radium and isotope) therapyincluding technicianmaterials and supplies *$300.00 copay forMedicare-covered diagnostic

radiology services.1 Nuclear medicine with SPECT

$0.00 copay for Medicare-covered lab services.1 Computerized tomography

20% of the cost for each Medicare-coveredmedical supplies.1 MRI

1 PET $35.00 copay for each Medicare-coveredtherapeutic radiology visit.1 Ultrasound

$15.00 copay for Medicare-covered X-rays.1 Interventional Radiology




*$225.00 copay for Medicare-covered sleepstudies.

1 Computerized Tomographic Angiography(CTA) Magnetic

Out-of-Network1 Sleep Studies

40% of the cost for eachMedicare-covered bloodservices.

1 Surgical supplies, such as dressings

1 Splints, casts and other devices used toreduce fractures and dislocations 40% of the cost for Medicare-covered

non-radiologic diagnostic procedures and tests.1 Laboratory tests

40% of the cost for Medicare-covered diagnosticradiology services.1 Blood - including storage and

administration. Coverage of whole bloodand packed red cells begins only with thefourth pint of blood that you need -you must either pay the costs for the first3 pints of blood you get in a calendar yearor have the blood donated by you orsomeone else. All other components ofblood are covered beginning with the firstpint used.

40% of the cost for Medicare-covered labservices.

40% of the cost for Medicare-covered medicalsupplies.

40% of the cost for each Medicare-coveredtherapeutic radiology visit.

40% of the cost for Medicare-covered X-rays.1 Other outpatient diagnostic tests 40% of the cost for Medicare-covered sleep

studies.

Outpatient hospital services

The cost shares for services outlined underOutpatient hospital services are in the appropriatesections of this Benefit Chart.

We cover medically-necessary services you getin the outpatient department of a hospital fordiagnosis or treatment of an illness or injury.

Please refer to Medically Necessary Medical orSurgical Services in a Physician’s Office

Covered services include, but are not limited to:

1 Services in an emergency department oroutpatient clinic, such as observation servicesor outpatient surgery

Please refer to Emergency Care

Please refer to Outpatient Mental Health Care1 Laboratory and diagnostic tests billed by thehospital

Please refer to Outpatient Diagnostic Tests andTherapeutic Services and Supplies

1 Mental health care, including care in apartial-hospitalization program, if a doctorcertifies that inpatient treatment would berequired without it

Please refer to Outpatient Diagnostic Tests andTherapeutic Services and Supplies

Refer to the benefits proceeded by the “Apple”icon




Please refer to Medicare Part B PrescriptionDrugs

1 X-rays and other radiology services billed bythe hospital

1 Medical supplies such as splints and casts

1 Certain screenings and preventive services

1 Certain drugs and biologicals that you can’tgive yourself

Note: Unless the provider has written an orderto admit you as an inpatient to the hospital, youare an outpatient and pay the cost-sharingamounts for outpatient hospital services. Even ifyou stay in the hospital overnight, you might stillbe considered an “outpatient.” If you are not sureif you are an outpatient, you should ask thehospital staff.

You can also find more information in aMedicare fact sheet called “Are You a HospitalInpatient or Outpatient? If You Have Medicare– Ask!” This fact sheet is available on the Webathttp://www.medicare.gov/Publications/Pubs/pdf/11435.pdfor by calling 1-800-MEDICARE(1-800-633-4227). TTY/TDD users call1-877-486-2048. You can call these numbers forfree, 24 hours a day, 7 days a week.

In-NetworkOutpatient mental health care

$40.00 copay for each Medicare-covered grouptherapy visit provided by a non-physician.


Mental health services provided by astate-licensed psychiatrist or doctor, clinical $40.00 copay for each Medicare-covered

individual therapy visit provided by anon-physician.

psychologist, clinical social worker, clinical nursespecialist, nurse practitioner, physician assistant,or other Medicare-qualified mental health care $40.00 copay for each Medicare-covered group

therapy visit with a psychiatrist.professional as allowed under applicable statelaws.

$40.00 copay for each Medicare-coveredindividual therapy visit with a psychiatrist.

Out-of-Network




40% of the cost for eachMedicare-covered grouptherapy visit provided by a non-physician.

40% of the cost for each Medicare-coveredindividual therapy visit provided by anon-physician.

40% of the cost for eachMedicare-covered grouptherapy visit with a psychiatrist.

40% of the cost for each Medicare-coveredindividual therapy visit with a psychiatrist.

In-NetworkOutpatient rehabilitation services

$35.00 copay for each Medicare-coveredOccupational Therapy visit.

Covered services include: physical therapy,occupational therapy, and speech languagetherapy. $1,940 of Medicare allowed annual maximumOutpatient rehabilitation services are providedin various outpatient settings, such as hospital

$35.00 copay for eachMedicare-covered Physicaland/or Speech and Language Therapy visit.

outpatient departments, independent therapist$1,940 of Medicare allowed combined annualoffices, and Comprehensive Outpatient

Rehabilitation Facilities (CORFs). maximum

*Authorization is required after the 15th visit.

Out-of-Network

40% of the cost for each Medicare-coveredOccupational Therapy visit.

$1,940 of Medicare allowed annual maximum

40% of the cost for each Medicare-coveredPhysical and/or Speech and Language Therapyvisit.

$1,940 of Medicare allowed combined annual

maximum

*Authorization is required after the 15th visit.

In-NetworkOutpatient substance abuse services




$40.00 copay for Medicare-covered grouptherapy visits.

Non-residential services provided for thetreatment of drug or alcohol dependence, withoutthe use of pharmacotherapies. Services may $40.00 copay for Medicare-covered individual

therapy visits.include intensive outpatient services (all-day carefor several days) as well as traditional counseling(one or a few hours per day, usually weekly orbiweekly). Out-of-Network

40% of the cost for Medicare-covered grouptherapy visits.

40% of the cost forMedicare-covered individualtherapy visits.

In-NetworkOutpatient surgery, including servicesprovided at hospital outpatient facilities andambulatory surgical centers

*$225.00 copay for each Medicare-coveredambulatory surgical center service.

Note: If you are having surgery in a hospitalfacility, you should check with your provider

*$225.00 copay for each Medicare-coveredoutpatient hospital service.

about whether you will be an inpatient oroutpatient. Unless the provider writes an orderto admit you as an inpatient to the hospital, you Out-of-Networkare an outpatient and pay the cost-sharing

40% of the cost for each Medicare-coveredambulatory surgical center service.

amounts for outpatient surgery. Even if you stayin the hospital overnight, you might still beconsidered an “outpatient.” 40% of the cost for each Medicare-covered

outpatient hospital service.

In-NetworkPartial hospitalization services

*$0.00 copay per day for Medicare-coveredpartial hospitalization program services.

“Partial hospitalization” is a structured programof active psychiatric treatment provided in ahospital outpatient setting or by a community Out-of-Networkmental health center, that is more intense than

40% of the cost for Medicare-covered partialhospitalization program services.

the care received in your doctor’s or therapist’soffice and is an alternative to inpatienthospitalization.

In-NetworkPhysician/Practitioner services, includingdoctor’s office visits $0.00 copay for eachMedicare-covered primary

care doctor visit.Covered services include:




$40.00 copay for each Medicare-coveredspecialist visit.

1 Medically-necessary medical care orsurgery services furnished in a physician’soffice, certified ambulatory surgical center,hospital outpatient department, or anyother location Out-of-Network

40% of the cost for each Medicare-coveredprimary care doctor visit.

1 Consultation, diagnosis, and treatment bya specialist

40% of the cost for each Medicare-coveredspecialist visit.

1 Basic hearing and balance examsperformed by your PCP, if your doctororders it to see if you need medicaltreatment.

1 Second opinion prior to surgery

1 Non-routine dental care (covered servicesare limited to surgery of the jaw or relatedstructures, setting fractures of the jaw orfacial bones, extraction of teeth to preparethe jaw for radiation treatments ofneoplastic cancer disease, or services thatwould be covered when provided by aphysician)

In-NetworkPodiatry services

*$40.00 copay for each Medicare-covered visit.Covered services include:

Out-of-Network1 Diagnosis and the medical or surgicaltreatment of injuries and diseases of the feet(such as hammer toe or heel spurs).

40% of the cost for eachMedicare-covered visit.

1 Routine foot care for members with certainmedical conditions affecting the lower limbs

In-NetworkProstate cancer screening exams

For men age 50 and older, covered servicesinclude the following - once every 12 months:

There is no coinsurance, copayment, ordeductible for an annual PSA test.

Out-of-Network1 Digital rectal exam 40% of the cost for Medicare-covered prostate

cancer screening exams.1 Prostate Specific Antigen (PSA) test




If your provider performs additional diagnosticor surgical procedures, or if other medicalservices are provided for othermedical conditionsduring the same visit, then the appropriate costshare applies for those services rendered duringthat visit

In-NetworkProsthetic devices and related supplies

*20% of the cost for each Medicare-coveredprosthetic or orthotic device and related supplies.

Devices (other than dental) that replace all or partof a body part or function. These include, but arenot limited to: colostomy bags and supplies Out-of-Networkdirectly related to colostomy care, pacemakers,

40% of the cost for each Medicare-coveredprosthetic or orthotic device and related supplies.

braces, prosthetic shoes, artificial limbs, andbreast prostheses (including a surgical brassiereafter a mastectomy). Includes certain suppliesrelated to prosthetic devices, and repair and/orreplacement of prosthetic devices. Also includessome coverage following cataract removal orcataract surgery – see “Vision Care” later in thissection for more detail.

In-NetworkPulmonary rehabilitation services

*$0.00 copay for Medicare-covered PulmonaryRehabilitation Services.

Out-of-Network

Comprehensive programs of pulmonaryrehabilitation are covered for members who havemoderate to very severe chronic obstructivepulmonary disease (COPD) and an order for

40% of the cost for Medicare-coveredPulmonary/Cardiac Rehabilitation Services.

pulmonary rehabilitation from the doctor treatingthe chronic respiratory disease.

In-NetworkReadmission Prevention

*Readmission Prevention Care is provided tomembers upon discharge from a facility or SNF.$10.00 copay per visit (in-a-home setting) witha $500.00 max per year.(Services can not exceed 4 weeks perauthorization period)

Our plan offers a Home Health Aide serviceavailable to all members transitioning froman acute, skilled, or other inpatient setting tohome. The goals are to safely transition to ahome setting and to prevent readmission. Theseservices are not duplicate to Medicare-coveredbenefits as no skilled need exists. Services will Out-of-Networkbe initiated immediately (e.g. within 1 week) of




40% of the cost for Medicare-coveredReadmission Prevention Care.

a member's discharge and provided on a limitedand specified period of time not to exceed 4weeks per authorized period. $500.00 max benefit per year.

In-NetworkScreening and counseling to reduce

alcohol misuse

We cover one alcohol misuse screening for adultswithMedicare (including pregnant women) whomisuse alcohol, but aren’t alcohol dependent.

There is no coinsurance, copayment, ordeductible for the Medicare-covered screeningand counseling to reduce alcohol misusepreventive benefit.

If you screen positive for alcohol misuse, youcan get up to 4 brief face-to-face counseling

Out-of-Network

40% of the cost for Medicare-covered screeningand counseling to reduce alcohol misuse.

sessions per year (if you’re competent and alertduring counseling) provided by a qualifiedprimary care doctor or practitioner in a primarycare setting.


In-NetworkScreening for sexually transmitted

infections (STIs) and counseling to preventSTIs

We cover sexually transmitted infection (STI)screenings for chlamydia, gonorrhea, syphilis,

There is no coinsurance, copayment, ordeductible for the Medicare-covered screeningfor STIs and counseling to prevent STIspreventive benefit.

and Hepatitis B. These screenings are coveredOut-of-Networkfor pregnant women and for certain people who

are at increased risk for an STI when the tests 40% of the cost for Medicare-covered screeningfor sexually transmitted infections (STIs) andcounseling to prevent STIs.

are ordered by a primary care provider. We coverthese tests once every 12 months or at certaintimes during pregnancy.

If your provider performs additional diagnosticor surgical procedures, or if other medicalWe also cover up to 2 individual 20 to 30 minute,

face-to-face high-intensity behavioral counseling services are provided for othermedical conditionssessions each year for sexually active adults at during the same visit, then the appropriate costincreased risk for STIs. We will only cover these share applies for those services rendered during

that visit.counseling sessions as a preventive service if




they are provided by a primary care provider andtake place in a primary care setting, such as adoctor’s office.

In-NetworkServices to treat kidney disease and conditions

*$30.00 copay for each Medicare-coveredoutpatient renal dialysis treatment. Includes homeand facility dialysis treatments.


1 Kidney disease education services to teachkidney care and helpmembersmake informeddecisions about their care. For members withstage IV chronic kidney disease when referredby their doctor, we cover up to six sessionsof kidney disease education services perlifetime.

$0.00 copay forMedicare-covered kidney diseaseeducation services.

Out-of-Network

20% of the cost for each Medicare-coveredoutpatient renal dialysis treatment. Inlcudes homedialysis treatments.1 Outpatient dialysis treatments (including

dialysis treatments when temporarily out ofthe service area, as explained in Chapter 3) 40% of the cost for Medicare-covered kidney

disease education services.1 Inpatient dialysis treatments (if you areadmitted as an inpatient to a hospital forspecial care)

1 Self-dialysis training (includes training foryou and anyone helping you with your homedialysis treatments)

1 Home dialysis equipment and supplies

1 Certain home support services (such as, whennecessary, visits by trained dialysis workersto check on your home dialysis, to help inemergencies, and check your dialysisequipment and water supply)

Certain drugs for dialysis are covered under yourMedicare Part B drug benefit. For informationabout coverage for Part B Drugs, please go tothe section, “Medicare Part B prescription drugs.”

In-NetworkSkilled nursing facility (SNF) care

*Days 1 - 20: $0.00 copay per dayDays 21 - 100: $150.00 copay per day.

(For a definition of “skilled nursing facility care,”see Chapter 12 of this booklet. Skilled nursingfacilities are sometimes called “SNFs.”)




No prior hospital stay required to access SNFcare.

Out-of-Network

40% of the cost for each Medicare-covered SNFstay.Covered services include but are not limited to:

1 Semiprivate room (or a private room ifmedically necessary)

1 Meals, including special diets

1 Skilled nursing services

1 Physical therapy, occupational therapy,and speech therapy

1 Drugs administered to you as part of yourplan of care (This includes substances thatare naturally present in the body, such asblood clotting factors.)

1 Blood - including storage andadministration. Coverage of whole bloodand packed red cells begins only with thefourth pint of blood that you need - youmust either pay the costs for the first 3pints of blood you get in a calendar yearor have the blood donated by you orsomeone else. All other components ofblood are covered beginning with the firstpint used. Medical and surgical suppliesordinarily provided by SNFs

1 Laboratory tests ordinarily provided bySNFs

1 X-rays and other radiology servicesordinarily provided by SNFs

1 Use of appliances such as wheelchairsordinarily provided by SNFs

1 Physician/Practitioner services

Generally, you will get your SNF care fromnetwork facilities. However, under certainconditions listed below, you may be able to payin-network cost-sharing for a facility that isn’t a




network provider, if the facility accepts our plan’samounts for payment.

1 A nursing home or continuing careretirement community where you wereliving right before you went to the hospital(as long as it provides skilled nursingfacility care).

1 A SNF where your spouse is living at thetime you leave the hospital.

In-NetworkSmoking and tobacco use cessation

(counseling to stop smoking or tobacco use)

If you use tobacco, but do not have signs orsymptoms of tobacco-related disease: We cover

There is no coinsurance, copayment, ordeductible for the Medicare-covered smokingand tobacco use cessation preventive benefits.

two counseling quit attempts within a 12-monthOut-of-Networkperiod as a preventive service with no cost to

you. Each counseling attempt includes up to fourface-to-face visits.

40% of the cost for Medicare-covered smokingcessation counseling services.

If you use tobacco and have been diagnosed witha tobacco-related disease or are taking medicine


that may be affected by tobacco: We cover services are provided for othermedical conditionscessation counseling services. We cover two during the same visit, then the appropriate costcounseling quit attempts within a 12-month share applies for those services rendered during

that visit.period, however, you will pay the applicableinpatient or outpatient cost-sharing. Eachcounseling attempt includes up to fourface-to-face visits.

In-NetworkUrgently needed services

$40.00 copay for each visit in an Urgent CareCenter.

Urgently needed services are provided to treat anon-emergency, unforeseen medical illness,injury, or condition that requires immediatemedical care. Urgently needed services may be

Out-of-Networkfurnished by network providers or byout-of-network providers when network $40.00 copay for each visit in an Urgent Care

Center.providers are temporarily unavailable orinaccessible.




This coverage is world-wide and not limited towithin the US.

In-NetworkVision care

Covered services include:$0.00 copay for one pair of eyeglasses or contactlenses following cataract surgery that includesinsertion of an intraocular lens. Non-surgical

1 Outpatient physician services for thediagnosis and treatment of diseases andinjuries of the eye, including treatment forage-relatedmacular degeneration. OriginalMedicare doesn’t cover routine eye exams(eye refractions) for eyeglasses/contacts.

need for eyewear or contact lenses has a $100allowance every two (2) years.

$0.00 copay when services are rendered bypreferred vision vendor. $100.00 allowance everytwo (2) years for eyewear and contacts.

$40.00 copay for Medicare-covered visionservices rendered by an opthamologist. $0.00

1 For people who are at high risk ofglaucoma, such as people with a familyhistory of glaucoma, people with diabetes,and African-Americans who are age 50and older: glaucoma screening once peryear.

copay when services are rendered by anoptician/optometrist.

$0.00 copay for Medicare-covered Glaucomascreening.

1 One pair of eyeglasses or contact lensesafter each cataract surgery that includesinsertion of an intraocular lens. (If youhave two separate cataract operations, youcannot reserve the benefit after the firstsurgery and purchase two eyeglasses afterthe second surgery.)

Out-of-Network

40% of the cost for one pair of eyeglasses orcontact lenses following cataract surgery thatincludes insertion of an intraocular lens.Non-surgical need for eyewear or contact lenseshas a $100 allowance every two (2) years.1 Routine Eye Exam40% of the cost for annual routine vision exam.Contact lenses; Eyewear- eyeglass lenses and

frames. 40% of the cost for Medicare-covered visionservices rendered by a MD.

40% of the cost for Medicare-covered Glaucomascreening.





In-Network“Welcome toMedicare” PreventiveVisit

The plan covers the one-time “Welcome toMedicare” preventive visit. The visit includes a

There is no coinsurance, copayment, ordeductible for the “Welcome to Medicare”preventive visit.

review of your health, as well as education and Out-of-Networkcounseling about the preventive services you

40% of the cost for this preventive service.need (including certain screenings and shots),and referrals for other care if needed. If your provider performs additional diagnostic

or surgical procedures, or if other medicalImportant:We cover the “Welcome toMedicare” preventive visit only within the first services are provided for othermedical conditions

during the same visit, then the appropriate cost12 months you haveMedicare Part B.When youshare applies for those services rendered duringthat visit.

make your appointment, let your doctor’s officeknow youwould like to schedule your “Welcometo Medicare” preventive visit.

Section 2.2 Extra “optional supplemental” benefits you can buy

Our plan offers some extra benefits that are not covered by Original Medicare and not included inyour benefits package as a plan member. These extra benefits are called “Optional SupplementalBenefits.” If you want these optional supplemental benefits, you must sign up for them and youmay have to pay an additional premium for them. The optional supplemental benefits described inthis section are subject to the same appeals process as any other benefits.

The Memorial Hermann Advantage PPO Pack (MHAP) is an enhancement package of benefits:Dental, Eyewear Chiropractic and Worldwide Emergent and Urgent services that you can buy asa single optional benefit; that is all benefits are purchased together for a single monthly premium.At the time of your enrollment, you will be given the opportunity to choose the Memorial HermannAdvantage PPO Pack as an optional benefit, in addition to the basic plan benefits, by indicatingyour preference on the enrollment form.Members who are already enrolled withMemorial HermannAdvantage PPO for 2015, will be sent out, through the Annual Notice of Change, information anda short enrollment form that can be completed and sent back to the health plan if they choose topurchase the benefits. Enrollment for this optional package occurs only one time a year, eitherduring the CMS Annual Enrollment Period (AEP) or outside of the AEP timeline if you are newto the plan and eligible for a Special Election Period (SEP).

The effective date for the MHAP is the same effective date as when your Memorial HermannAdvantage PPO benefits go into effect. You will receive a letter from us stating your effective date.You will be responsible for a monthly premium of $49.00, to be paid in advance. This means, yourfirst bill will be sent to you in the first month of your eligibility, requesting payment for the first


and secondmonths. From that point on, you will pay in advance of the eligible month. Your monthlypremium will be due by the first of each month.

You may voluntarily drop or discontinue the Memorial Hermann Advantage PPO Pack benefitpackage at any time during the contract year upon proper advance 30-day notice. A Notice ofDiscontinuation letter will be sent to you with the stated effected date. The discontinuation of thebenefits will go into effect on the 1st of the month following notification. You will not be responsiblefor any premium payments after the discontinuation effective date. You will not be eligible tore-enroll for the Memorial Hermann Advantage PPO Pack benefit during the same year youdiscontinued the package; you will have to wait for the next Annual Enrollment Period for the nextbenefit year.

If you have paid a full annual premium in advance you will be entitled to a pro-rated refund forthe months remaining in the year, number of months from your discontinuation date to the lastmonth of the year. Your refund will be mailed to you within 30 days of your discontinuation effectivedate. Once discontinuation of the optional benefits goes into effect, you will no longer be eligiblefor the benefits.

If you fail to pay your premium for two (2) consecutive months (grace period); we will begin thediscontinuation process from the optional benefit for you. At the end of your grace period, we willinform you in writing of our intention to roll you back to our basic Medicare plan benefits. In thenotice youwill be given an effective date of the discontinuation of theMemorial HermannAdvantagePPO Pack.

If we receive the past due balance prior to the effective date, your benefits will stay in place. If wedo not receive past due payments by the effective date, your discontinuation date will go into effect.

Discontinuation of Memorial Hermann Advantage PPO Pack benefits will not dis-enroll you fromour base plan and there will be no gap in coverage for your Medicare benefits.

Supplement Benefits Chart

What you must pay whenyou get these services


In-NetworkChiropractic services

$25.00 copay per visit forRoutine Care


1 Optional Routine CareLimited to 15 visits per year

Out of Network

$25.00 copay per visit forRoutine Care

Limited to 15 visits per year




In-NetworkDental services

Preventive Dental Services:Preventive dental services: include cleaning, routine dental exams,and dental x-rays. You pay a $0.00 copay for

preventive services1 Oral Exams – Up to two oral exams per year

Comprehensive DentalServices:

1 Prophylaxis (cleanings) – Up to two cleanings per year

1 Fluoride Treatment – Up to two fluoride treatments per year1 You pay 25% forminor services1 Dental X-rays

1 Bitewing x-rays (2 films) – Up to one Bitewing x-ray per year1 You pay 70% for majorservices1 Full mouth or Panoramic x-ray – Up to one Full Mouth or

Panoramic x-ray every 36 months. Authorization: NoMinor Restorative dental services: Limitations : Yes, $1500

plan maximum benefit peryear

1 Periodontal Scaling and Root Planning (Deep Cleaning) -Up to one per quadrant every 36 months

1 Amalgam Restoration (fillings) – Up to two fillings per year

Out of Network1 Simple Extractions – Up to two extractions per year

Preventive Dental Services:Major Dental Services:You pay a $0.00 copay forpreventive services

1 Crowns – Up to one crown per year

1 Root Canal Treatment – Up to one root canal per yearComprehensive DentalServices:Complete or Partial Dentures – Up to one complete and one partial

denture every 36 months.1 You pay 25% forminor services

1 You pay 70% for majorservices

Authorization: No

Limitations : Yes, $1500plan maximum benefit peryear

In-NetworkEyewear services

$225.00 maximum planbenefit coverage per year

1 Eyeglasses (frames & lenses) – Up to one pair per year -$225 benefit and vendor discount




or

Out of Network1 Contact lenses and fitting – Up to one pair per year - $225benefit and vendor discount $225.00 maximum plan

benefit coverage per yearLimitations and Exclusions:

Orthoptic or vision training and any associated supplemental training

In-NetworkHearing Aid


Out of Network


In-NetworkWorldwide Emergency /Urgent Coverage

$0.00 copay for worldwideemergent/urgent coverage.

Out of Network

$0.00 copay for worldwideemergent/urgent coverage.

SECTION 3 What services are not covered by the plan?

Section 3.1 Services we do not cover (exclusions)

This section tells you what services are “excluded” from Medicare coverage and therefore, are notcovered by this plan. If a service is “excluded,” it means that this plan doesn’t cover the service.

The chart below lists services and items that either are not covered under any condition or arecovered only under specific conditions.

If you get services that are excluded (not covered), you must pay for them yourself. We won’t payfor the excluded medical services listed in the chart below except under the specific conditionslisted. The only exception: we will pay if a service in the chart below is found upon appeal to be amedical service that we should have paid for or covered because of your specific situation. (For


information about appealing a decision we havemade to not cover a medical service, go to Chapter 9,Section 5.3 in this booklet.)

All exclusions or limitations on services are described in the Benefits Chart or in the chart below.

Even if you receive the excluded services at an emergency facility, the excluded services are stillnot covered and our plan will not pay for them.

Covered only under specific conditionsNot covered under anycondition

Services not covered byMedicare

√Services considered not reasonableand necessary, according to thestandards of Original Medicare

√Experimental medical and surgicalprocedures, equipment andmedications.

May be covered by Original Medicareunder a Medicare-approved clinicalresearch study or by our plan.Experimental procedures and items

are those items and procedures (See Chapter 3, Section 5 for moreinformation on clinical research studies.)determined by our plan and

Original Medicare to not begenerally accepted by the medicalcommunity.

√Private room in a hospital.

Covered only whenmedically necessary.

√Personal items in your room at ahospital or a skilled nursingfacility, such as a telephone or atelevision.

√Full-time nursing care in yourhome.

√*Custodial care is care provided ina nursing home, hospice, or otherfacility setting when you do notrequire skilled medical care orskilled nursing care.

√Homemaker services include basichousehold assistance, includinglight housekeeping or light mealpreparation.


Covered only under specific conditionsNot covered under anycondition

Services not covered byMedicare

√Fees charged for care by yourimmediate relatives or members ofyour household.

√Cosmetic surgery or procedures

1 Covered in cases of an accidentalinjury or for improvement of thefunctioning of a malformed bodymember.

1 Covered for all stages ofreconstruction for a breast after amastectomy, as well as for theunaffected breast to produce asymmetrical appearance.

√Routine foot care

Some limited coverage providedaccording to Medicare guidelines, e.g.,if you have diabetes.

√Orthopedic shoes

If shoes are part of a leg brace and areincluded in the cost of the brace, or theshoes are for a person with diabetic footdisease.

√Supportive devices for the feet

Orthopedic or therapeutic shoes forpeople with diabetic foot disease.

√Reversal of sterilization proceduresand or non-prescriptioncontraceptive supplies.

√Acupuncture

√Naturopath services (uses naturalor alternative treatments).

*Custodial care is personal care that does not require the continuing attention of trained medicalor paramedical personnel, such as care that helps you with activities of daily living, such as bathingor dressing.


CHAPTER 5Using the plan’s

coverage for your Part Dprescription drugs

Chapter 5. Using the plan’s coverage for your Part D prescription drugs

SECTION 1 Introduction ..........................................................................................91

Section 1.1 This chapter describes your coverage for Part D drugs .................................. 91

Section 1.2 Basic rules for the plan’s Part D drug coverage ............................................. 91

SECTION 2 Fill your prescription at a network pharmacy or through the plan’smail-order service ................................................................................92

Section 2.1 To have your prescription covered, use a network pharmacy ........................ 92

Section 2.2 Finding network pharmacies .......................................................................... 92

Section 2.3 Using the plan’s mail-order services .............................................................. 93

Section 2.4 How can you get a long-term supply of drugs? .............................................. 94

Section 2.5 When can you use a pharmacy that is not in the plan’s network? .................. 94

SECTION 3 Your drugs need to be on the plan’s “Drug List” .............................. 95

Section 3.1 The “Drug List” tells which Part D drugs are covered ................................... 95

Section 3.2 There are five (5) “cost-sharing tiers” for drugs on the Drug List ................. 96

Section 3.3 How can you find out if a specific drug is on the Drug List? ......................... 96

SECTION 4 There are restrictions on coverage for some drugs ......................... 97

Section 4.1 Why do some drugs have restrictions? ........................................................... 97

Section 4.2 What kinds of restrictions? ............................................................................. 97

Section 4.3 Do any of these restrictions apply to your drugs? .......................................... 98

SECTION 5 What if one of your drugs is not covered in the way you’d like itto be covered? ......................................................................................98

Section 5.1 There are things you can do if your drug is not covered in the way you’dlike it to be covered ........................................................................................ 98

Section 5.2 What can you do if your drug is not on the Drug List or if the drug isrestricted in some way? .................................................................................. 99

Section 5.3 What can you do if your drug is in a cost-sharing tier you think is toohigh? ............................................................................................................. 101

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 89Chapter 5. Using the plan’s coverage for your Part D prescription drugs

SECTION 6 What if your coverage changes for one of your drugs? ................ 102

Section 6.1 The Drug List can change during the year ................................................... 102

Section 6.2 What happens if coverage changes for a drug you are taking? .................... 102

SECTION 7 What types of drugs are not covered by the plan? ........................ 103

Section 7.1 Types of drugs we do not cover .................................................................... 103

SECTION 8 Show your plan membership card when you fill a prescription .... 104

Section 8.1 Show your membership card ........................................................................ 104

Section 8.2 What if you don’t have your membership card with you? ........................... 104

SECTION 9 Part D drug coverage in special situations ..................................... 105

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that iscovered by the plan? ..................................................................................... 105

Section 9.2 What if you’re a resident in a long-term care (LTC) facility? ...................... 105

Section 9.3 What if you’re also getting drug coverage from an employer or retiree groupplan? .............................................................................................................. 106

Section 9.4 What if you’re in Medicare-certified hospice? ............................................. 106

SECTION 10 Programs on drug safety and managing medications ................... 107

Section 10.1 Programs to help members use drugs safely ................................................ 107

Section 10.2 Medication TherapyManagement (MTM) program to helpmembersmanagetheir medications ........................................................................................... 107


Did you know there are programs to help people pay for their drugs?There are programs to help people with limited resources pay for their drugs. These include“Extra Help” and State Pharmaceutical Assistance Programs. For more information, seeChapter 2, Section 7.

Are you currently getting help to pay for your drugs?If you are in a program that helps pay for your drugs, some information in this Evidenceof Coverage about the costs for Part D prescription drugs may not apply to you.Wehave included a separate insert, called the “Evidence of Coverage Rider for People WhoGet Extra Help Paying for Prescription Drugs” (also known as the “Low Income SubsidyRider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t havethis insert, please call Customer Service and ask for the “LIS Rider.” (Phone numbers forCustomer Service are printed on the back cover of this booklet.)


Section 1.1 This chapter describes your coverage for Part D drugs

This chapter explains rules for using your coverage for Part D drugs. The next chapter tellswhat you pay for Part D drugs (Chapter 6, What you pay for your Part D prescription drugs).

In addition to your coverage for Part D drugs, Memorial Hermann Advantage PPO also coverssome drugs under the plan’s medical benefits. Through its coverage of Medicare A benefits, ourplan generally covers drugs you are given during covered stays in the hospital or in a skilled nursingfacility. Through its coverage of Medicare Part B benefits, our plan covers drugs including certainchemotherapy drugs, certain drug injections you are given during an office visit, and drugs you aregiven at a dialysis facility. Chapter 4 (Medical Benefits Chart, what is covered and what you pay)tells about the benefits and costs for drugs during a covered hospital or skilled nursing facility stay,as well as your benefits and costs for Part B drugs.

Your drugs may be covered by Original Medicare if you are in Medicare hospice. Our plan onlycovers Medicare Parts A, B, and D services and drugs that are unrelated to your terminal prognosisand related conditions and therefore not covered under the Medicare hospice benefit. For moreinformation, please see Section 9.4 (What if you’re in Medicare-certified hospice). For informationon hospice coverage and Part C, see the hospice section of Chapter 4 (Medical Benefits Chart, whatis covered and what you pay).

The following sections discuss coverage of your drugs under the plan’s Part D benefit rules.Section 9, Part D drug coverage in special situations includes more information on your Part Dcoverage and Original Medicare.

Section 1.2 Basic rules for the plan’s Part D drug coverage

The plan will generally cover your drugs as long as you follow these basic rules:


1 You must have a provider (a doctor, dentist or other prescriber) write your prescription.

1 Your prescriber must either accept Medicare or file documentation with CMS showing thathe or she is qualified to write prescriptions, or your Part D claim will be denied. You shouldask your prescribers the next time you call or visit if they meet this condition. If not, pleasebe aware it takes time for your prescriber to submit the necessary paperwork to be processed.

1 You generally must use a network pharmacy to fill your prescription. (See Section 2, Fillyour prescriptions at a network pharmacy or through the plan’s mail-order service.)

1 Your drug must be on the plan’s List of Covered Drugs (Formulary) (we call it the “DrugList” for short). (See Section 3, Your drugs need to be on the plan’s “Drug List.”)

1 Your drugmust be used for a medically accepted indication. A “medically accepted indication”is a use of the drug that is either approved by the Food and Drug Administration or supportedby certain reference books. (See Section 3 for more information about a medically acceptedindication.)

SECTION 2 Fill your prescription at a network pharmacy or throughthe plan’s mail-order service

Section 2.1 To have your prescription covered, use a network pharmacy

In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies.(See Section 2.5 for information about when we would cover prescriptions filled at out-of-networkpharmacies.)

A network pharmacy is a pharmacy that has a contract with the plan to provide your coveredprescription drugs. The term “covered drugs” means all of the Part D prescription drugs that arecovered on the plan’s Drug List.

Section 2.2 Finding network pharmacies

How do you find a network pharmacy in your area?To find a network pharmacy, you can look in your Pharmacy Directory, visit our website(healthplan.memorialhermann.org/medicare), or call Customer Service (phone numbers are printedon the back cover of this booklet).

Youmay go to any of our network pharmacies. If you switch from one network pharmacy to another,and you need a refill of a drug you have been taking, you can ask either to have a new prescriptionwritten by a provider or to have your prescription transferred to your new network pharmacy.

What if the pharmacy you have been using leaves the network?If the pharmacy you have been using leaves the plan’s network, you will have to find a new pharmacythat is in the network. To find another network pharmacy in your area, you can get help from


Customer Service (phone numbers are printed on the back cover of this booklet) or use thePharmacyDirectory. You can also find information on our website athealthplan.memorialhermann.org/medicare.

What if you need a specialized pharmacy?Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include:

1 Pharmacies that supply drugs for home infusion therapy.

1 Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, along-term care facility (such as a nursing home) has its own pharmacy. If you are in an LTCfacility, we must ensure that you are able to routinely receive your Part D benefits throughour network of LTC pharmacies, which is typically the pharmacy that the LTC facility uses.If you have any difficulty accessing your Part D benefits in an LTC facility, please contactCustomer Service.

1 Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (notavailable in Puerto Rico). Except in emergencies, only Native Americans or Alaska Nativeshave access to these pharmacies in our network.

1 Pharmacies that dispense drugs that are restricted by the FDA to certain locations or thatrequire special handling, provider coordination, or education on their use. (Note: This scenarioshould happen rarely.)

To locate a specialized pharmacy, look in your Pharmacy Directory or call Customer Service (phonenumbers are printed on the back cover of this booklet).

Section 2.3 Using the plan’s mail-order services

For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the drugsprovided through mail order are drugs that you take on a regular basis, for a chronic or long-termmedical condition. The drugs available through our plan’s mail-order service are marked as“mail-order” drugs in our Drug List.

Our plan’s mail-order service allows you to order up to a 90-day supply.

To get order forms and information about filling your prescriptions by mail call Customer Service(phone numbers for Customer Service are on the back cover of this booklet). If you use a mailorder pharmacy not in the plan’s network, your prescription will not be covered.

Usually a mail-order pharmacy order will get to you in no more than 14 days. If you experience adelay and require an immediate prescription, you can call Customer Service to request a supplyfrom a retail pharmacy.

New prescriptions the pharmacy receives directly from your doctor’s office.After the pharmacy receives a prescription from a health care provider, it will contact you to see ifyou want the medication filled immediately or at a later time. This will give you an opportunity tomake sure that the pharmacy is delivering the correct drug (including strength, amount, and form)and, if needed, allow you to stop or delay the order before you are billed and it is shipped. It is


important that you respond each time you are contacted by the pharmacy, to let them know whatto do with the new prescription and to prevent any delays in shipping.

Refills on mail order prescriptions. For refills, please contact your pharmacy 15 days before youthink the drugs you have on hand will run out to make sure your next order is shipped to you intime.

So the pharmacy can reach you to confirm your order before shipping, please make sure to let thepharmacy know the best ways to contact you. Please call the mail-order pharmacy at 1-866-909-5170(TTY/TDD 711) to inform them of your communication preference for any automatic shipments.

Section 2.4 How can you get a long-term supply of drugs?

When you get a long-term supply of drugs, your cost-sharing may be lower. The plan offers twoways to get a long-term supply (also called an “extended supply”) of “maintenance” drugs on ourplan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic orlong-term medical condition.) You may order this supply through mail order (see Section 2.3) oryou may go to a retail pharmacy.

1. Some retail pharmacies in our network allow you to get a long-term supply of maintenancedrugs. Some of these retail pharmacies agree to accept a lower cost-sharing amount for along-term supply of maintenance drugs. YourPharmacy Directory tells you which pharmaciesin our network can give you a long-term supply of maintenance drugs. You can also callCustomer Service for more information (phone numbers are printed on the back cover of thisbooklet).

2. For certain kinds of drugs, you can use the plan’s networkmail-order services. The drugsavailable through our plan’s mail-order service are marked as “mail-order” drugs in ourDrug List. Our plan’s mail-order service allows you to order a 90-day supply. See Section2.3 for more information about using our mail-order services.

Section 2.5 When can you use a pharmacy that is not in the plan’s network?

Your prescription may be covered in certain situationsGenerally, we cover drugs filled at an out-of-network pharmacy only when you are not able to usea network pharmacy. To help you, we have network pharmacies outside of our service area whereyou can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy,here are the circumstances when wewould cover prescriptions filled at an out-of-network pharmacy:

1 Non-routine situations when a network pharmacy is not available.

1 If you are traveling within the United States and territories and you become ill, run out orlose your prescription drugs.

1 Prescriptions that are written as part of a medical emergency or urgent care visit.


In these situations, please check first with Customer Service to see if there is a network pharmacynearby. (Phone numbers for Customer Service are printed on the back cover of this booklet.) Youmay be required to pay the difference between what you pay for the drug at the out-of-networkpharmacy and the cost that we would cover at an in-network pharmacy.

How do you ask for reimbursement from the plan?If you must use an out-of-network pharmacy, you will generally have to pay the full cost (ratherthan your normal share of the cost) at the time you fill your prescription. You can ask us to reimburseyou for our share of the cost. (Chapter 7, Section 2.1 explains how to ask the plan to pay you back.)

SECTION 3 Your drugs need to be on the plan’s “Drug List”

Section 3.1 The “Drug List” tells which Part D drugs are covered

The plan has a “List of Covered Drugs (Formulary).” In this Evidence of Coverage, we call it the“Drug List” for short.

The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists.The list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List.

The drugs on the Drug List are only those covered under Medicare Part D (earlier in this chapter,Section 1.1 explains about Part D drugs).

We will generally cover a drug on the plan’s Drug List as long as you follow the other coveragerules explained in this chapter and the use of the drug is a medically accepted indication. A“medically accepted indication” is a use of the drug that is either:

1 Approved by the Food and Drug Administration. (That is, the Food and Drug Administrationhas approved the drug for the diagnosis or condition for which it is being prescribed.)

1 -- or -- Supported by certain reference books. (These reference books are the AmericanHospital Formulary Service Drug Information; the DRUGDEX Information System; and theUSPDI or its successor; and, for cancer, the National Comprehensive Cancer Network andClinical Pharmacology or their successors.)

The Drug List includes both brand name and generic drugsA generic drug is a prescription drug that has the same active ingredients as the brand name drug.Generally, it works just as well as the brand name drug and usually costs less. There are genericdrug substitutes available for many brand name drugs.

What is not on the Drug List?The plan does not cover all prescription drugs.

1 In some cases, the law does not allow any Medicare plan to cover certain types of drugs (formore about this, see Section 7.1 in this chapter).


1 In other cases, we have decided not to include a particular drug on our Drug List.

Section 3.2 There are five (5) “cost-sharing tiers” for drugs on the Drug List

Every drug on the plan’s Drug List is in one of five (5) cost-sharing tiers. In general, the higher thecost-sharing tier, the higher your cost for the drug:

1 Tier 1: (Preferred Generic)

Tier 1 is your lowest-cost Generic tier and includes preferred generic drugs. Generic drugs containthe same active ingredients as brand drugs and are equally safe and effective.

1 Tier 2: (Generic)

This is your higher-cost Generic tier and includes generic drugs and sometimes some preferredbrand drugs. Some Tier 2 drugs have lower-cost Tier 1 alternatives. Ask your doctor if you coulduse a Tier 1 to lower your out-of-pocket expenses.

1 Tier 3: (Preferred Brand)

This is your middle-cost tier, and includes preferred brand. Some Tier 3 drugs have lower-cost Tier1 or 2 alternatives. Ask your doctor if you could use a Tier 1 or Tier 2 drug to lower yourout-of-pocket expenses.

1 Tier 4 (Non-Preferred Brand)

This is your higher-cost tier and includes non-preferred brand drugs. Some Tier 4 drugs havelower-cost Tier 1, 2, or 3 alternatives. Ask your doctor if you could use a Tier 1, Tier 2, or Tier 3drug to lower your out-of-pocket expenses.

1 Tier 5 (Specialty Tier Drugs)

The Specialty tier is your highest-cost tier. A Specialty drug is a very high cost or unique prescriptiondrug which may require special handling and/or close monitoring. Specialty Tier Drugs may bebrand or generic.

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.

The amount you pay for drugs in each cost-sharing tier is shown in Chapter 6 (What you pay foryour Part D prescription drugs).

Section 3.3 How can you find out if a specific drug is on the Drug List?

You have three (3) ways to find out:

1. Check the most recent Drug List we sent you in the mail. (Please note: The Drug List wesend includes information for the covered drugs that aremost commonly used by ourmembers.However, we cover additional drugs that are not included in the printed Drug List. If one ofyour drugs is not listed in the Drug List, you should visit our website or contact CustomerService to find out if we cover it.)


2. Visit the plan’s website (healthplan.memorialhermann.org/medicare). The Drug List on thewebsite is always the most current.

3. Call Customer Service to find out if a particular drug is on the plan’s Drug List or to ask fora copy of the list. (Phone numbers for Customer Service are printed on the back cover of thisbooklet.)

SECTION 4 There are restrictions on coverage for some drugs

Section 4.1 Why do some drugs have restrictions?

For certain prescription drugs, special rules restrict how and when the plan covers them. A teamof doctors and pharmacists developed these rules to help our members use drugs in the most effectiveways. These special rules also help control overall drug costs, which keeps your drug coveragemore affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safeand effective. Whenever a safe, lower-cost drug will work just as well medically as a higher-costdrug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option.We also need to comply with Medicare’s rules and regulations for drug coverage and cost-sharing.

If there is a restriction for your drug, it usually means that you or your provider will have totake extra steps in order for us to cover the drug. If you want us to waive the restriction for you,you will need to use the coverage decision process and ask us to make an exception. We may ormay not agree to waive the restriction for you. (See Chapter 9, Section 6.2 for information aboutasking for exceptions.)

Please note that sometimes a drug may appear more than once in our drug list. This is becausedifferent restrictions or cost-sharing may apply based on factors such as the strength, amount, orform of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; oneper day versus two per day; tablet versus liquid).

Section 4.2 What kinds of restrictions?

Our plan uses different types of restrictions to help our members use drugs in the most effectiveways. The sections below tell you more about the types of restrictions we use for certain drugs.

Restricting brand name drugs when a generic version is availableGenerally, a “generic” drug works the same as a brand name drug and usually costs less. In mostcases, when a generic version of a brand name drug is available, our network pharmacies willprovide you the generic version.We usually will not cover the brand name drug when a genericversion is available. However, if your provider has told us the medical reason that neither the genericdrug nor other covered drugs that treat the same condition will work for you, then we will coverthe brand name drug. (Your share of the cost may be greater for the brand name drug than for thegeneric drug.)


Getting plan approval in advanceFor certain drugs, you or your provider need to get approval from the plan before we will agree tocover the drug for you. This is called “prior authorization.” Sometimes the requirement for gettingapproval in advance helps guide appropriate use of certain drugs. If you do not get this approval,your drug might not be covered by the plan.

Trying a different drug firstThis requirement encourages you to try less costly but just as effective drugs before the plan coversanother drug. For example, if Drug A and Drug B treat the same medical condition, the plan mayrequire you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.This requirement to try a different drug first is called “step therapy.”

Quantity limitsFor certain drugs, we limit the amount of the drug that you can have by limiting how much of adrug you can get each time you fill your prescription. For example, if it is normally considered safeto take only one pill per day for a certain drug, we may limit coverage for your prescription to nomore than one pill per day.

Section 4.3 Do any of these restrictions apply to your drugs?

The plan’s Drug List includes information about the restrictions described above. To find out ifany of these restrictions apply to a drug you take or want to take, check the Drug List. For the mostup-to-date information, call Customer Service (phone numbers are printed on the back cover ofthis booklet) or check our website (healthplan.memorialhermann.org/medicare).

If there is a restriction for your drug, it usually means that you or your provider will have totake extra steps in order for us to cover the drug. If there is a restriction on the drug you wantto take, you should contact Customer Service to learn what you or your provider would need to doto get coverage for the drug. If you want us to waive the restriction for you, you will need to usethe coverage decision process and ask us to make an exception. We may or may not agree to waivethe restriction for you. (See Chapter 9, Section 6.2 for information about asking for exceptions.)

SECTION 5 What if one of your drugs is not covered in the way you’dlike it to be covered?

Section 5.1 There are things you can do if your drug is not covered in the wayyou’d like it to be covered

We hope that your drug coverage will work well for you. But it’s possible that there could be aprescription drug you are currently taking, or one that you and your provider think you should betaking that is not on our formulary or is on our formulary with restrictions. For example:


1 The drug might not be covered at all. Or maybe a generic version of the drug is covered butthe brand name version you want to take is not covered.

1 The drug is covered, but there are extra rules or restrictions on coverage for that drug. Asexplained in Section 4, some of the drugs covered by the plan have extra rules to restrict theiruse. For example, you might be required to try a different drug first, to see if it will work,before the drug you want to take will be covered for you. Or there might be limits on whatamount of the drug (number of pills, etc.) is covered during a particular time period. In somecases, you may want us to waive the restriction for you.

1 The drug is covered, but it is in a cost-sharing tier that makes your cost-sharingmore expensivethan you think it should be. The plan puts each covered drug into one of five (5) differentcost-sharing tiers. How much you pay for your prescription depends in part on whichcost-sharing tier your drug is in.

There are things you can do if your drug is not covered in the way that you’d like it to be covered.Your options depend on what type of problem you have:

1 If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learnwhat you can do.

1 If your drug is in a cost-sharing tier that makes your cost more expensive than you think itshould be, go to Section 5.3 to learn what you can do.

Section 5.2 What can you do if your drug is not on the Drug List or if the drugis restricted in some way?

If your drug is not on the Drug List or is restricted, here are things you can do:

1 You may be able to get a temporary supply of the drug (only members in certain situationscan get a temporary supply). This will give you and your provider time to change to anotherdrug or to file a request to have the drug covered.

1 You can change to another drug.

1 You can request an exception and ask the plan to cover the drug or remove restrictions fromthe drug.

You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when yourdrug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talkwith your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:

1 The drug you have been taking is no longer on the plan’s Drug List.

1 -- or -- the drug you have been taking is now restricted in some way (Section 4 in thischapter tells about restrictions).


2. You must be in one of the situations described below:

1 For those members who are new or who were in the plan last year and aren’t in along-term care (LTC) facility:

We will cover a temporary supply of your drug during the first (90 days) of yourmembership in the plan if you were new and during the first (90 days) of the calendaryear if you were in the plan last year. This temporary supply will be for a maximum of(30-day supply). If your prescription is written for fewer days, we will allow multiple fillsto provide up to a maximum of (30-day supply) of medication. The prescription must befilled at a network pharmacy.

1 For those members who are new or who were in the plan last year and reside in along-term care (LTC) facility:

We will cover a temporary supply of your drug during the first (90 days) of yourmembership in the plan if you are new and during the first (90 days) of the calendaryear if you were in the plan last year. The total supply will be for a maximum of (93-days).If your prescription is written for fewer days, we will allow multiple fills to provide up to amaximum of (93-day supply) of medication. (Please note that the long-term care pharmacymay provide the drug in smaller amounts at a time to prevent waste.)

1 For those members who have been in the plan for more than (90 days) and reside in along-term care (LTC) facility and need a supply right away:

We will cover one (31-day supply) of a particular drug, or less if your prescription is writtenfor fewer days. This is in addition to the above long-term care transition supply.

1 When you transfer from one treatment setting to another, such as moving from aninpatient hospital setting to home, it is called a level-of-care change.

These types of changes often do not leave you enough time to determine if a new prescriptioncontains a drug that is not on the plan Drug List. In these unexpected situations, we will covera temporary 30-day transition supply or a 31-day transition supply if you reside in a long-termcare facility (unless you have a prescription written for fewer days).

To ask for a temporary supply, call Customer Service (phone numbers are printed on the back coverof this booklet).

During the time when you are getting a temporary supply of a drug, you should talk with yourprovider to decide what to do when your temporary supply runs out. You can either switch to adifferent drug covered by the plan or ask the plan to make an exception for you and cover yourcurrent drug. The sections below tell you more about these options.

You can change to another drug

Start by talking with your provider. Perhaps there is a different drug covered by the plan that mightwork just as well for you. You can call Customer Service to ask for a list of covered drugs that treat


the same medical condition. This list can help your provider find a covered drug that might workfor you. (Phone numbers for Customer Service are printed on the back cover of this booklet.)

You can ask for an exception

You and your provider can ask the plan to make an exception for you and cover the drug in theway you would like it to be covered. If your provider says that you have medical reasons that justifyasking us for an exception, your provider can help you request an exception to the rule. For example,you can ask the plan to cover a drug even though it is not on the plan’s Drug List. Or you can askthe plan to make an exception and cover the drug without restrictions.

If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. Itexplains the procedures and deadlines that have been set by Medicare to make sure your request ishandled promptly and fairly.

Section 5.3 What can you do if your drug is in a cost-sharing tier you think istoo high?

If your drug is in a cost-sharing tier you think is too high, here are things you can do:

You can change to another drugIf your drug is in a cost-sharing tier you think is too high, start by talking with your provider.Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you.You can call Customer Service to ask for a list of covered drugs that treat the samemedical condition.This list can help your provider find a covered drug that might work for you. (Phone numbers forCustomer Service are printed on the back cover of this booklet.)

You can ask for an exceptionFor drugs in Tier 2 and Tier 4, you and your provider can ask the plan to make an exception in thecost-sharing tier for the drug so that you pay less for it. If your provider says that you have medicalreasons that justify asking us for an exception, your provider can help you request an exception tothe rule.

If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. Itexplains the procedures and deadlines that have been set by Medicare to make sure your request ishandled promptly and fairly.

Drugs in our Tier five (5) are not eligible for this type of exception.We do not lower the cost-sharingamount for drugs in this tier.


SECTION 6 What if your coverage changes for one of your drugs?

Section 6.1 The Drug List can change during the year

Most of the changes in drug coverage happen at the beginning of each year (January 1). However,during the year, the plan might make changes to the Drug List. For example, the plan might:

1 Add or remove drugs from the Drug List. New drugs become available, including newgeneric drugs. Perhaps the government has given approval to a new use for an existing drug.Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drugfrom the list because it has been found to be ineffective.

1 Move a drug to a higher or lower cost-sharing tier.

1 Add or remove a restriction on coverage for a drug (for more information about restrictionsto coverage, see Section 4 in this chapter).

1 Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the plan’s DrugList.

Section 6.2 What happens if coverage changes for a drug you are taking?

How will you find out if your drug’s coverage has been changed?If there is a change to coverage for a drug you are taking, the plan will send you a notice to tellyou. Normally, we will let you know at least 60 days ahead of time.

Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for otherreasons. If this happens, the plan will immediately remove the drug from the Drug List. We willlet you know of this change right away. Your provider will also know about this change, and canwork with you to find another drug for your condition.

Do changes to your drug coverage affect you right away?If any of the following types of changes affect a drug you are taking, the change will not affect youuntil January 1 of the next year if you stay in the plan:

1 If we move your drug into a higher cost-sharing tier.

1 If we put a new restriction on your use of the drug.

1 If we remove your drug from the Drug List, but not because of a sudden recall or because anew generic drug has replaced it.

If any of these changes happens for a drug you are taking, then the change won’t affect your useor what you pay as your share of the cost until January 1 of the next year. Until that date, youprobably won’t see any increase in your payments or any added restriction to your use of the drug.However, on January 1 of the next year, the changes will affect you.


In some cases, you will be affected by the coverage change before January 1:

1 If a brand name drug you are taking is replaced by a new generic drug, the plan mustgive you at least 60 days’ notice or give you a 60-day refill of your brand name drug at anetwork pharmacy.

4 During this 60-day period, you should be working with your provider to switch to thegeneric or to a different drug that we cover.

4 Or you and your provider can ask the plan to make an exception and continue to coverthe brand name drug for you. For information on how to ask for an exception, see Chapter 9(What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

1 Again, if a drug is suddenly recalled because it’s been found to be unsafe or for other reasons,the plan will immediately remove the drug from the Drug List. We will let you know of thischange right away.

4 Your provider will also know about this change, and can work with you to find anotherdrug for your condition.

SECTION 7 What types of drugs are not covered by the plan?

Section 7.1 Types of drugs we do not cover

This section tells you what kinds of prescription drugs are “excluded.” This means Medicare doesnot pay for these drugs.

If you get drugs that are excluded, you must pay for them yourself. We won’t pay for the drugsthat are listed in this section. The only exception: If the requested drug is found upon appeal to bea drug that is not excluded under Part D and we should have paid for or covered it because of yourspecific situation. (For information about appealing a decision we have made to not cover a drug,go to Chapter 9, Section 6.5 in this booklet.)

Here are three general rules about drugs that Medicare drug plans will not cover under Part D:

1 Our plan’s Part D drug coverage cannot cover a drug that would be covered under MedicarePart A or Part B.

1 Our plan cannot cover a drug purchased outside the United States and its territories.

1 Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other thanthose indicated on a drug’s label as approved by the Food and Drug Administration.

4 Generally, coverage for “off-label use” is allowed only when the use is supported bycertain reference books. These reference books are the American Hospital FormularyService Drug Information, the DRUGDEX Information System, for cancer, the NationalComprehensive Cancer Network and Clinical Pharmacology, or their successors. If theuse is not supported by any of these reference books, then our plan cannot cover its“off-label use.”


Also, by law, these categories of drugs are not covered by Medicare drug plans:

1 Non-prescription drugs (also called over-the-counter drugs).

1 Drugs when used to promote fertility.

1 Drugs when used for the relief of cough or cold symptoms.

1 Drugs when used for cosmetic purposes or to promote hair growth.

1 Prescription vitamins andmineral products, except prenatal vitamins and fluoride preparations.

1 Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis,Levitra, and Caverject.

1 Drugs when used for treatment of anorexia, weight loss, or weight gain.

1 Outpatient drugs for which themanufacturer seeks to require that associated tests or monitoringservices be purchased exclusively from the manufacturer as a condition of sale.

If you receive “Extra Help” paying for your drugs, your state Medicaid program may coversome prescription drugs not normally covered in a Medicare drug plan. Please contact your stateMedicaid program to determine what drug coverage may be available to you. (You can find phonenumbers and contact information for Medicaid in Chapter 2, Section 6.)

SECTION 8 Show your plan membership card when you fill aprescription

Section 8.1 Show your membership card

To fill your prescription, show your plan membership card at the network pharmacy you choose.When you show your plan membership card, the network pharmacy will automatically bill the planfor our share of your covered prescription drug cost. You will need to pay the pharmacy your shareof the cost when you pick up your prescription.

Section 8.2 What if you don’t have your membership card with you?

If you don’t have your plan membership card with you when you fill your prescription, ask thepharmacy to call the plan to get the necessary information.

If the pharmacy is not able to get the necessary information, you may have to pay the full cost ofthe prescription when you pick it up. (You can then ask us to reimburse you for our share. SeeChapter 7, Section 2.1 for information about how to ask the plan for reimbursement.)


SECTION 9 Part D drug coverage in special situations

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a staythat is covered by the plan?

If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, wewill generally cover the cost of your prescription drugs during your stay. Once you leave the hospitalor skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of our rulesfor coverage. See the previous parts of this section that tell about the rules for getting drug coverage.Chapter 6 (What you pay for your Part D prescription drugs) gives more information about drugcoverage and what you pay.

Please Note:When you enter, live in, or leave a skilled nursing facility, you are entitled to a SpecialEnrollment Period. During this time period, you can switch plans or change your coverage.(Chapter 10, Ending your membership in the plan, tells when you can leave our plan and join adifferent Medicare plan.)

Section 9.2 What if you’re a resident in a long-term care (LTC) facility?

Usually, a long-term care facility (LTC) (such as a nursing home) has its own pharmacy, or apharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility,you may get your prescription drugs through the facility’s pharmacy as long as it is part of ournetwork.

Check your Pharmacy Directory to find out if your long-term care facility’s pharmacy is part ofour network. If it isn’t, or if you need more information, please contact Customer Service (phonenumbers are printed on the back cover of this booklet).

What if you’re a resident in a long-term care (LTC) facility and become a newmemberof the plan?If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover atemporary supply of your drug during the first (90 days) of your membership. The total supplywill be for a maximum of (93-day), or less if your prescription is written for fewer days. (Pleasenote that the long-term care pharmacy may provide the drug in smaller amounts at a time to preventwaste.) If you have been a member of the plan for more than (90 days) and need a drug that is noton our Drug List or if the plan has any restriction on the drug’s coverage, we will cover one (31-day)supply, or less if your prescription is written for fewer days.

During the time when you are getting a temporary supply of a drug, you should talk with yourprovider to decide what to do when your temporary supply runs out. Perhaps there is a differentdrug covered by the plan that might work just as well for you. Or you and your provider can askthe plan to make an exception for you and cover the drug in the way you would like it to be covered.If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do.


Section 9.3 What if you’re also getting drug coverage from an employer orretiree group plan?

Do you currently have other prescription drug coverage through your (or your spouse’s) employeror retiree group? If so, please contact that group’s benefits administrator. He or she can helpyou determine how your current prescription drug coverage will work with our plan.

In general, if you are currently employed, the prescription drug coverage you get from us will besecondary to your employer or retiree group coverage. That means your group coverage would payfirst.

Special note about ‘creditable coverage’:Each year your employer or retiree group should send you a notice that tells if your prescriptiondrug coverage for the next calendar year is “creditable” and the choices you have for drug coverage.

If the coverage from the group plan is “creditable,” it means that the plan has drug coverage thatis expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Keep these notices about creditable coverage, because you may need them later. If you enroll ina Medicare plan that includes Part D drug coverage, you may need these notices to show that youhave maintained creditable coverage. If you didn’t get a notice about creditable coverage from youremployer or retiree group plan, you can get a copy from the employer or retiree group’s benefitsadministrator or the employer or union.

Section 9.4 What if you’re in Medicare-certified hospice?

Drugs are never covered by both hospice and our plan at the same time. If you are enrolled inMedicare hospice and require an anti-nausea, laxative, pain medication or antianxiety drug that isnot covered by your hospice because it is unrelated to your terminal illness and related conditions,our plan must receive notification from either the prescriber or your hospice provider that the drugis unrelated before our plan can cover the drug. To prevent delays in receiving any unrelated drugsthat should be covered by our plan, you can ask your hospice provider or prescriber to make surewe have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription.

In the event you either revoke your hospice election or are discharged from hospice our plan shouldcover all your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefitends, you should bring documentation to the pharmacy to verify your revocation or discharge. Seethe previous parts of this section that tell about the rules for getting drug coverage under Part DChapter 6 (What you pay for your Part D prescription drugs) gives more information about drugcoverage and what you pay.


SECTION 10 Programs on drug safety and managing medications

Section 10.1 Programs to help members use drugs safely

We conduct drug use reviews for our members to help make sure that they are getting safe andappropriate care. These reviews are especially important for members who have more than oneprovider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis.During these reviews, we look for potential problems such as:

1 Possible medication errors

1 Drugs that may not be necessary because you are taking another drug to treat the samemedicalcondition

1 Drugs that may not be safe or appropriate because of your age or gender

1 Certain combinations of drugs that could harm you if taken at the same time

1 Prescriptions written for drugs that have ingredients you are allergic to

1 Possible errors in the amount (dosage) of a drug you are taking.

If we see a possible problem in your use of medications, we will work with your provider to correctthe problem.

Section 10.2 Medication Therapy Management (MTM) program to help membersmanage their medications

We have a program that can help our members with complex health needs. For example, somemembers have several medical conditions, take different drugs at the same time, and have highdrug costs.

This program is voluntary and free to members. A team of pharmacists and doctors developed theprogram for us. This program can help make sure that our members get the most benefit from thedrugs they take.

Our program is called a Medication Therapy Management (MTM) program. Some members whotake medications for different medical conditions may be able to get services through a MTMprogram. A pharmacist or other health professional will give you a comprehensive review of allyour medications. You can talk about how best to take your medications, your costs, and anyproblems or questions you have about your prescription and over-the-counter medications. You’llget a written summary of this discussion. The summary has amedication action plan that recommendswhat you can do to make the best use of your medications, with space for you to take notes or writedown any follow-up questions. You’ll also get a personal medication list that will include all themedications you’re taking and why you take them.


It’s a good idea to have your medication review before your yearly “Wellness” visit, so you cantalk to your doctor about your action plan andmedication list. Bring your action plan andmedicationlist with you to your visit or anytime you talk with your doctors, pharmacists, and other health careproviders. Also, keep your medication list with you (for example, with your ID) in case you go tothe hospital or emergency room.

If we have a program that fits your needs, we will automatically enroll you in the program and sendyou information. If you decide not to participate, please notify us and we will withdraw you fromthe program. If you have any questions about these programs, please contact Customer Service(phone numbers are printed on the back cover of this booklet).


CHAPTER 6What you pay for your

Part D prescription drugs

Chapter 6. What you pay for your Part D prescription drugs

SECTION 1 Introduction ........................................................................................112

Section 1.1 Use this chapter together with other materials that explain your drugcoverage ........................................................................................................ 112

Section 1.2 Types of out-of-pocket costs you may pay for covered drugs ...................... 113

SECTION 2 What you pay for a drug depends onwhich “drug payment stage”you are in when you get the drug .....................................................113

Section 2.1 What are the drug payment stages for Memorial Hermann AdvantagePPO members? ............................................................................................. 113

SECTION 3 We send you reports that explain payments for your drugs andwhich payment stage you are in .......................................................114

Section 3.1 We send you a monthly report called the “Part D Explanation of Benefits”(the “Part D EOB”) ....................................................................................... 114

Section 3.2 Help us keep our information about your drug payments up to date ........... 115

SECTION 4 During the Deductible Stage, you pay the full cost of your Tier 1,Tier 2, Tier 3, Tier 4 and Tier 5 drugs ................................................ 116

Section 4.1 You stay in the Deductible Stage until you have paid $100.00 for your Tier1, Tier 2,Tier 3, Tier 4 and Tier 5 drugs ....................................................... 116

SECTION 5 During the Initial Coverage Stage, the plan pays its share of yourdrug costs and you pay your share ................................................. 116

Section 5.1 What you pay for a drug depends on the drug and where you fill yourprescription ................................................................................................... 116

Section 5.2 A table that shows your costs for a one-month supply of a drug .................. 117

Section 5.3 If your doctor prescribes less than a full month’s supply, you may not haveto pay the cost of the entire month’s supply ................................................. 118

Section 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of adrug ............................................................................................................... 119

Section 5.5 You stay in the Initial Coverage Stage until your total drug costs for theyear reach $3,310.00 ..................................................................................... 120

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 110Chapter 6. What you pay for your Part D prescription drugs

SECTION 6 During the Coverage Gap Stage, the plan provides some drugcoverage .............................................................................................121

Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach$4,850.00 ...................................................................................................... 121

Section 6.2 How Medicare calculates your out-of-pocket costs for prescriptiondrugs ............................................................................................................. 121

SECTION 7 During the Catastrophic Coverage Stage, the plan pays most ofthe cost for your drugs ......................................................................123

Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this stagefor the rest of the year ................................................................................... 123

SECTION 8 What you pay for vaccinations covered by Part D depends on howand where you get them ....................................................................124

Section 8.1 Our plan may have separate coverage for the Part D vaccine medicationitself and for the cost of giving you the vaccine ........................................... 124

Section 8.2 You may want to call us at Customer Service before you get avaccination .................................................................................................... 125

SECTION 9 Do you have to pay the Part D “late enrollment penalty”? ............ 126

Section 9.1 What is the Part D “late enrollment penalty”? .............................................. 126

Section 9.2 How much is the Part D late enrollment penalty? ........................................ 126

Section 9.3 In some situations, you can enroll late and not have to pay the penalty ....... 127

Section 9.4 What can you do if you disagree about your late enrollment penalty? ........ 127

SECTION 10 Do you have to pay an extra Part D amount because of yourincome? ..............................................................................................128

Section 10.1 Who pays an extra Part D amount because of income? ............................... 128

Section 10.2 How much is the extra Part D amount? ........................................................ 128

Section 10.3 What can you do if you disagree about paying an extra Part D amount? ..... 129

Section 10.4 What happens if you do not pay the extra Part D amount? .......................... 129


Did you know there are programs to help people pay for their drugs?There are programs to help people with limited resources pay for their drugs. These include“Extra Help” and State Pharmaceutical Assistance Programs. For more information, seeChapter 2, Section 7.

Are you currently getting help to pay for your drugs?If you are in a program that helps pay for your drugs, some information in this Evidenceof Coverage about the costs for Part D prescription drugs does not apply to you.Wehave included a separate insert, called the “Evidence of Coverage Rider for People WhoGet Extra Help Paying for Prescription Drugs” (also known as the “Low Income SubsidyRider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t havethis insert, please call Customer Service and ask for the “LIS Rider.” (Phone numbers forCustomer Service are printed on the back cover of this booklet.)


Section 1.1 Use this chapter together with other materials that explain yourdrug coverage

This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple,we use “drug” in this chapter to mean a Part D prescription drug. As explained in Chapter 5, notall drugs are Part D drugs – some drugs are covered under Medicare Part A or Part B and otherdrugs are excluded from Medicare coverage by law.

To understand the payment information we give you in this chapter, you need to know the basicsof what drugs are covered, where to fill your prescriptions, and what rules to follow when you getyour covered drugs. Here are materials that explain these basics:

1 The plan’s List of Covered Drugs (Formulary). To keep things simple, we call this the“Drug List.”

4 This Drug List tells which drugs are covered for you.

4 It also tells which of the five (5) “cost-sharing tiers” the drug is in and whether there areany restrictions on your coverage for the drug.

4 If you need a copy of the Drug List, call Customer Service (phone numbers are printedon the back cover of this booklet). You can also find the Drug List on our website athealthplan.memorialhermann.org/medicare. The Drug List on the website is always themost current.

1 Chapter 5 of this booklet.Chapter 5 gives the details about your prescription drug coverage,including rules you need to follow when you get your covered drugs. Chapter 5 also tellswhich types of prescription drugs are not covered by our plan.


1 The plan’s Pharmacy Directory. In most situations you must use a network pharmacy toget your covered drugs (see Chapter 5 for the details). The Pharmacy Directory has a list ofpharmacies in the plan’s network. It also tells you which pharmacies in our network can giveyou a long-term supply of a drug (such as filling a prescription for a three-month’s supply).

Section 1.2 Types of out-of-pocket costs you may pay for covered drugs

To understand the payment information we give you in this chapter, you need to know about thetypes of out-of-pocket costs you may pay for your covered services. The amount that you pay fora drug is called “cost-sharing,” and there are three ways you may be asked to pay.

1 The “deductible” is the amount you must pay for drugs before our plan begins to pay itsshare.

1 “Copayment” means that you pay a fixed amount each time you fill a prescription.

1 “Coinsurance” means that you pay a percent of the total cost of the drug each time you filla prescription.

SECTION 2 What you pay for a drug depends onwhich “drug paymentstage” you are in when you get the drug

Section 2.1 What are the drug payment stages forMemorial HermannAdvantagePPO members?

As shown in the table below, there are “drug payment stages” for your prescription drug coverageunder Memorial Hermann Advantage PPO. How much you pay for a drug depends on which ofthese stages you are in at the time you get a prescription filled or refilled.

Stage 4

CatastrophicCoverage Stage

Stage 3

Coverage Gap Stage

Stage 2

Initial Coverage Stage

Stage 1

Yearly Deductible Stage

During this stage, theplan will paymost of

For generic drugs, youpay a $0.00 copaymentfor a 30-day supply of

During this stage, theplan pays its share of thecost of your generic

You begin in thispayment stage whenyou fill your firstprescription of the year.

the cost of your drugsfor the rest of theTier 1 Preferred Generic

drugs. For Tier 2 Genericdrugs and you pay yourshare of the cost.During this stage, you

pay the full cost of

calendar year(through December31, 2016).

drugs, you pay a $5.00copayment or 58% of thecosts, whichever is

After you (or others onyour behalf) have metyour Tier 1, Tier 2, Tier

your Tier 1, Tier 2,Tier3, Tier 4 and Tier 5drugs.


Stage 4

CatastrophicCoverage Stage

Stage 3

Coverage Gap Stage

Stage 2

Initial Coverage Stage

Stage 1

Yearly Deductible Stage

(Details are inSection 7 of thischapter.)

lower. For brand namedrugs, you pay 45% ofthe price (plus a portionof the dispensing fee).

3, Tier 4, and Tier 5deductible, the planspays its share of the costsof your Tier 1, Tier 2,

You stay in this stageuntil you have paid$100.00 for your Tier 1,Tier 2, Tier 3, Tier 4and Tier 5 drugs Tier 3, Tier 4, and Tier 5

drugs and you pay yourshare.

($100.00 is the amountof your Tier 1, Tier 2,

You stay in this stageuntil your year-to-date

You stay in this stageuntil your year-to-date

Tier 3, Tier 4 and Tier5 drug deductible).

“out-of-pocket costs”(your payments) reach a

“total drug costs” (your(Details are in Section4 of this chapter.)

total of $4,850.00 Thisamount and rules forcounting costs toward

payments plus any PartD plan’s payments) total$3,310.00. this amount have been

set by Medicare.(Details are in Section 5of this chapter.) (Details are in Section 6

of this chapter.)

SECTION 3 We send you reports that explain payments for your drugsand which payment stage you are in

Section 3.1 We send you a monthly report called the “Part D Explanation ofBenefits” (the “Part D EOB”)

Our plan keeps track of the costs of your prescription drugs and the payments you have made whenyou get your prescriptions filled or refilled at the pharmacy. This way, we can tell you when youhave moved from one drug payment stage to the next. In particular, there are two types of costs wekeep track of:

1 We keep track of how much you have paid. This is called your “out-of-pocket” cost.

1 We keep track of your “total drug costs.” This is the amount you pay out-of-pocket or otherspay on your behalf plus the amount paid by the plan.

Our plan will prepare a written report called the Part D Explanation of Benefits (it is sometimescalled the “Part D EOB”) when you have had one or more prescriptions filled through the planduring the previous month. It includes:


1 Information for that month. This report gives the payment details about the prescriptionsyou have filled during the previous month. It shows the total drugs costs, what the plan paid,and what you and others on your behalf paid.

1 Totals for the year since January 1. This is called “year-to-date” information. It shows youthe total drug costs and total payments for your drugs since the year began.

Section 3.2 Help us keep our information about your drug payments up to date

To keep track of your drug costs and the payments you make for drugs, we use records we get frompharmacies. Here is how you can help us keep your information correct and up to date:

1 Show your membership card when you get a prescription filled. To make sure we knowabout the prescriptions you are filling and what you are paying, show your plan membershipcard every time you get a prescription filled.

1 Make sure we have the information we need. There are times you may pay for prescriptiondrugs when we will not automatically get the information we need to keep track of yourout-of-pocket costs. To help us keep track of your out-of-pocket costs, you may give us copiesof receipts for drugs that you have purchased. (If you are billed for a covered drug, you canask our plan to pay our share of the cost. For instructions on how to do this, go to Chapter7, Section 2 of this booklet.) Here are some types of situations when you may want to giveus copies of your drug receipts to be sure we have a complete record of what you have spentfor your drugs:

4 When you purchase a covered drug at a network pharmacy at a special price or using adiscount card that is not part of our plan’s benefit.

4 When you made a copayment for drugs that are provided under a drug manufacturerpatient assistance program.

4 Any time you have purchased covered drugs at out-of-network pharmacies or other timesyou have paid the full price for a covered drug under special circumstances.

1 Send us information about the payments others have made for you. Payments made bycertain other individuals and organizations also count toward your out-of-pocket costs andhelp qualify you for catastrophic coverage. For example, payments made by a StatePharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the IndianHealth Service, and most charities count toward your out-of-pocket costs. You should keepa record of these payments and send them to us so we can track your costs.

1 Check the written report we send you.When you receive an Part D Explanation of Benefits(a Part D EOB) in the mail, please look it over to be sure the information is complete andcorrect. If you think something is missing from the report, or you have any questions, pleasecall us at Customer Service (phone numbers are printed on the back cover of this booklet).Be sure to keep these reports. They are an important record of your drug expenses.


SECTION 4 During the Deductible Stage, you pay the full cost of yourTier 1, Tier 2, Tier 3, Tier 4 and Tier 5 drugs

Section 4.1 You stay in the Deductible Stage until you have paid $100.00 foryour Tier 1, Tier 2,Tier 3, Tier 4 and Tier 5 drugs

The Deductible Stage is the first payment stage for your drug coverage. This stage begins whenyou fill your first prescription in the year. When you are in this payment stage, you must pay thefull cost of your drugs until you reach the plan’s deductible amount, which is $100.00 for 2016.

1 Your “full cost” is usually lower than the normal full price of the drug, since our plan hasnegotiated lower costs for most drugs.

1 The “deductible” is the amount you must pay for your Part D prescription drugs before theplan begins to pay its share.

Once you have paid $100.00 for your Tier 1, Tier 2, Tier 3, Tier 4 and Tier 5 drugs, you leave theDeductible Stage and move on to the next drug payment stage, which is the Initial Coverage Stage.

SECTION 5 During the Initial Coverage Stage, the plan pays its shareof your drug costs and you pay your share

Section 5.1 What you pay for a drug depends on the drug and where you fillyour prescription

During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescriptiondrugs, and you pay your share (your copayment or coinsurance amount). Your share of the costwill vary depending on the drug and where you fill your prescription.

The plan has five (5) cost-sharing tiers

Every drug on the plan’s Drug List is in one of five (5) cost-sharing tiers. In general, the higher thecost-sharing tier number, the higher your cost for the drug:

1 Tier 1: (Preferred Generic)Tier 1 is your lowest-cost Generic tier and includes preferred generic drugs. Generic drugscontain the same active ingredients as brand drugs and are equally safe and effective.

1 Tier 2: (Generic)This is your higher-cost Generic tier and includes generic drugs and sometimes some preferredbrand drugs. Some Tier 2 drugs have lower-cost Tier 1 alternatives. Ask your doctor if youcould use a Tier 1 to lower your out-of-pocket expenses.


1 Tier 3: (Preferred Brand)This is your middle-cost tier, and includes preferred brand. Some Tier 3 drugs have lower-costTier 1 or 2 alternatives. Ask your doctor if you could use a Tier 1 or Tier 2 drug to loweryour out-of-pocket expenses.

1 Tier 4 (Non-Preferred Brand)This is your higher-cost tier and includes non-preferred brand drugs. Some Tier 4 drugs havelower-cost Tier 1, 2, or 3 alternatives. Ask your doctor if you could use a Tier 1, Tier 2 orTier 3 drug to lower your out-of-pocket expenses.

1 Tier 5 (Specialty Tier Drugs)The Specialty tier is your highest-cost tier. A Specialty drug is a very high cost or uniqueprescription drug which may require special handling and/or close monitoring. Specialty TierDrugs may be brand or generic.

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.

Your pharmacy choices

How much you pay for a drug depends on whether you get the drug from:

1 A retail pharmacy that is in our plan’s network

1 A pharmacy that is not in the plan’s network

1 The plan’s mail-order pharmacy

For more information about these pharmacy choices and filling your prescriptions, see Chapter 5in this booklet and the plan’s Pharmacy Directory.

Section 5.2 A table that shows your costs for a one-month supply of a drug

During the Initial Coverage Stage, your share of the cost of a covered drug will be either a copaymentor coinsurance.

1 “Copayment” means that you pay a fixed amount each time you fill a prescription.

1 “Coinsurance” means that you pay a percent of the total cost of the drug each time you filla prescription.

As shown in the table below, the amount of the copayment or coinsurance depends on whichcost-sharing tier your drug is in. Please note:

1 If your covered drug costs less than the copayment amount listed in the chart, you will paythat lower price for the drug. You pay either the full price of the drug or the copaymentamount, whichever is lower.

1 We cover prescriptions filled at out-of-network pharmacies in only limited situations. Pleasesee Chapter 5, Section 2.5 for information about when we will cover a prescription filled atan out-of-network pharmacy.


Your share of the cost when you get a one-month supply of a covered Part Dprescription drug:

Out-of-networkcost-sharing

(Coverage is limited tocertain situations; seeChapter 5 for details.)(up to a 30-day supply)

Long-termcare (LTC)cost-sharing

(up to a31-daysupply)

Mail-ordercost-sharing


Standardretailcost-sharing(in-network)


$0.00$0.00$0.00$0.00Cost-Sharing Tier 1

(Preferred Generic Drug)


(Generic Drug)


(Preferred Brand Drug)


(Non-Preferred Brand Drug)

30%30%30%30%Cost-Sharing Tier 5

(Specialty)

Section 5.3 If your doctor prescribes less than a full month’s supply, you maynot have to pay the cost of the entire month’s supply

Typically, the amount you pay for a prescription drug covers you a full month’s supply of a covereddrug. However your doctor can prescribe less than a month’s supply of drugs. There may be timeswhen you want to ask your doctor about prescribing less than a month’s supply of a drug (forexample, when you are trying a medication for the first time that is known to have serious sideeffects). If your doctor prescribes less than a full month’s supply, you will not have to pay for thefull month’s supply for certain drugs.

The amount you pay when you get less than a full month’s supply will depend on whether you areresponsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat dollaramount).


1 If you are responsible for coinsurance, you pay a percentage of the total cost of the drug.You pay the same percentage regardless of whether the prescription is for a full month’ssupply or for fewer days. However, because the entire drug cost will be lower if you get lessthan a full month’s supply, the amount you pay will be less.

1 If you are responsible for a copayment for the drug, your copay will be based on the numberof days of the drug that you receive. We will calculate the amount you pay per day for yourdrug (the “daily cost-sharing rate”) and multiply it by the number of days of the drug youreceive.

1 Here’s an example: Let’s say the copay for your drug for a full month’s supply (a 30-daysupply) is $30. This means that the amount you pay per day for your drug is $1. If you receivea 7 days’ supply of the drug, your payment will be $1 per day multiplied by 7 days, for atotal payment of $7.

Daily cost-sharing allows you to make sure a drug works for you before you have to pay for anentire month’s supply. You can also ask your doctor to prescribe, and your pharmacist to dispense,less than a full month’s supply of a drug or drugs, if this will help you better plan refill date fordifferent prescriptions so that you can take fewer trips to the pharmacy. The amount you pay willdepend upon the days’ supply you receive.

Section 5.4 A table that shows your costs for a long-term (up to a 90-day) supplyof a drug

For some drugs, you can get a long-term supply (also called an “extended supply”) when you fillyour prescription. A long-term supply is up to a 90-day supply. (For details on where and how toget a long-term supply of a drug, see Chapter 5, Section 2.4.)

The table below shows what you pay when you get a long-term (up to a 90-day) supply of a drug.

1 Please note: If your covered drug costs less than the copayment amount listed in the chart,you will pay that lower price for the drug. You pay either the full price of the drug or thecopayment amount, whichever is lower.

Your share of the cost when you get a long-term supply of a covered Part Dprescription drug:

Mail-order cost-sharing

(up to a 90-day supply)

Standard retail cost-sharing(in-network)


$0.00$0.00Cost-Sharing Tier 1

(Preferred Generic Drug)


(Generic Drug)


Mail-order cost-sharing


Standard retail cost-sharing(in-network)



(Preferred Brand Drug)


(Non-Preferred Brand Drug)

30%30%Cost-Sharing Tier 5

(Specialty)

Section 5.5 You stay in the Initial Coverage Stage until your total drug costsfor the year reach $3,310.00

You stay in the Initial Coverage Stage until the total amount for the prescription drugs you havefilled and refilled reaches the $3,310.00 limit for the Initial Coverage Stage.

Your total drug cost is based on adding together what you have paid and what any Part D plan haspaid:

1 What you have paid for all the covered drugs you have gotten since you started with yourfirst drug purchase of the year. (See Section 6.2 for more information about how Medicarecalculates your out-of-pocket costs.) This includes:

4 The $100.00 you paid when you were in the Deductible Stage.

4 The total you paid as your share of the cost for your drugs during the Initial CoverageStage.

1 What the plan has paid as its share of the cost for your drugs during the Initial CoverageStage. (If you were enrolled in a different Part D plan at any time during 2016, the amountthat plan paid during the Initial Coverage Stage also counts toward your total drug costs.)

The Part D Explanation of Benefits (Part D EOB) that we send to you will help you keep track ofhow much you and the plan, as well as any third parties, have spent on your behalf for your drugsduring the year. Many people do not reach the $3,310.00 limit in a year.

We will let you know if you reach this $3,310.00 amount. If you do reach this amount, you willleave the Initial Coverage Stage and move on to the Coverage Gap Stage.


SECTION 6 During the Coverage Gap Stage, the plan provides somedrug coverage

Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costsreach $4,850.00

When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program providesmanufacturer discounts on brand name drugs. You pay 45% of the negotiated price and a portionof the dispensing fee for brand name drugs. Both the amount you pay and the amount discountedby the manufacturer count toward your out-of-pocket costs as if you had paid them and moves youthrough the coverage gap.

You also receive some coverage for generic drugs. You pay no more than 58% of the cost forgeneric drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (42%) doesnot count toward your out-of-pocket costs. Only the amount you pay counts andmoves you throughthe coverage gap.

You continue paying the discounted price for brand name drugs and no more than 58% of the costsof generic drugs until your yearly out-of-pocket payments reach a maximum amount that Medicarehas set. In 2016, that amount is $4,850.00.

Medicare has rules about what counts and what does not count as your out-of-pocket costs. Whenyou reach an out-of-pocket limit of $4,850.00, you leave the Coverage Gap Stage and move on tothe Catastrophic Coverage Stage.

Section 6.2 How Medicare calculates your out-of-pocket costs for prescriptiondrugs

Here are Medicare’s rules that we must follow when we keep track of your out-of-pocket costs foryour drugs.

These payments are included in your out-of-pocket costsWhen you add up your out-of-pocket costs, you can include the payments listed below (as longas they are for Part D covered drugs and you followed the rules for drug coverage that areexplained in Chapter 5 of this booklet):

1 The amount you pay for drugs when you are in any of the following drug payment stages:

4 The Deductible Stage.

4 The Initial Coverage Stage.

4 The Coverage Gap Stage.


1 Any payments you made during this calendar year as a member of a different Medicareprescription drug plan before you joined our plan.

It matters who pays:

1 If you make these payments yourself, they are included in your out-of-pocket costs.

1 These payments are also included if they aremade on your behalf by certain other individualsor organizations. This includes payments for your drugs made by a friend or relative, bymost charities, by AIDS drug assistance programs, by a State Pharmaceutical AssistanceProgram that is qualified by Medicare, or by the Indian Health Service. Payments made byMedicare’s “Extra Help” Program are also included.

1 Some of the payments made by the Medicare Coverage Gap Discount Program are included.The amount the manufacturer pays for your brand name drugs is included. But the amountthe plan pays for your generic drugs is not included.

Moving on to the Catastrophic Coverage Stage:

When you (or those paying on your behalf) have spent a total of $4,850.00 in out-of-pocketcosts within the calendar year, you will move from the Coverage Gap Stage to the CatastrophicCoverage Stage.

These payments are not included in your out-of-pocket costsWhen you add up your out-of-pocket costs, you are not allowed to include any of these typesof payments for prescription drugs:

1 Drugs you buy outside the United States and its territories.

1 Drugs that are not covered by our plan.

1 Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements forout-of-network coverage.

1 Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugsexcluded from Part D coverage by Medicare.

1 Payments made by the plan for your brand or generic drugs while in the Coverage Gap.

1 Payments for your drugs that are made by group health plans including employer healthplans.

1 Payments for your drugs that are made by certain insurance plans and government-fundedhealth programs such as TRICARE and the Veteran’s Administration.

1 Payments for your drugs made by a third-party with a legal obligation to pay for prescriptioncosts (for example, Worker’s Compensation).


Reminder: If any other organization such as the ones listed above pays part or all of yourout-of-pocket costs for drugs, you are required to tell our plan. Call Customer Service to let usknow (phone numbers are printed on the back cover of this booklet).

How can you keep track of your out-of-pocket total?1 We will help you. The Part D Explanation of Benefits (Part D EOB) report we send to youincludes the current amount of your out-of-pocket costs (Section 3 in this chapter tells aboutthis report). When you reach a total of $4,850.00 in out-of-pocket costs for the year, thisreport will tell you that you have left the Coverage Gap Stage and have moved on to theCatastrophic Coverage Stage.

1 Make sure we have the information we need. Section 3.2 tells what you can do to helpmake sure that our records of what you have spent are complete and up to date.

SECTION 7 During the Catastrophic Coverage Stage, the plan paysmost of the cost for your drugs

Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay inthis stage for the rest of the year

You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the$4,850.00 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you willstay in this payment stage until the end of the calendar year.

During this stage, the plan will pay most of the cost for your drugs.

1 Your share of the cost for a covered drug will be either coinsurance or a copayment,whichever is the larger amount:

4 – either – coinsurance of 5% of the cost of the drug

4 –or – $2.95 for a generic drug or a drug that is treated like a generic and $7.40 for allother drugs.

1 Our plan pays the rest of the cost.


SECTION 8 What you pay for vaccinations covered by Part D dependson how and where you get them

Section 8.1 Our plan may have separate coverage for the Part D vaccinemedication itself and for the cost of giving you the vaccine

Our plan provides coverage of a number of Part D vaccines. We also cover vaccines that areconsidered medical benefits. You can find out about coverage of these vaccines by going to theMedical Benefits Chart in Chapter 4, Section 2.1.

There are two parts to our coverage of Part D vaccinations:

1 The first part of coverage is the cost of the vaccine medication itself. The vaccine is aprescription medication.

1 The second part of coverage is for the cost of giving you the vaccine. (This is sometimescalled the “administration” of the vaccine.)

What do you pay for a Part D vaccination?What you pay for a Part D vaccination depends on three things:

1. The type of vaccine (what you are being vaccinated for).

4 Some vaccines are considered medical benefits. You can find out about your coverageof these vaccines by going to Chapter 4,Medical Benefits Chart (what is covered andwhat you pay).

4 Other vaccines are considered Part D drugs. You can find these vaccines listed in theplan’s List of Covered Drugs (Formulary).

2. Where you get the vaccine medication.

3. Who gives you the vaccine?

What you pay at the time you get the Part D vaccination can vary depending on the circumstances.For example:

1 Sometimes when you get your vaccine, you will have to pay the entire cost for both thevaccine medication and for getting the vaccine. You can ask our plan to pay you back forour share of the cost.

1 Other times, when you get the vaccine medication or the vaccine, you will pay only yourshare of the cost.

To show how this works, here are three common ways you might get a Part D vaccine. Rememberyou are responsible for all of the costs associated with vaccines (including their administration)during the Deductible and Coverage Gap Stage of your benefit.


Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccine at thenetwork pharmacy. (Whether you have this choice depends on where you live.Some states do not allow pharmacies to administer a vaccination.)

1 You will have to pay the pharmacy the amount of your copayment for thevaccine and the cost of giving you the vaccine.

1 Our plan will pay the remainder of the costs.

Situation 2: You get the Part D vaccination at your doctor’s office.

1 When you get the vaccination, you will pay for the entire cost of the vaccineand its administration.

1 You can then ask our plan to pay our share of the cost by using theprocedures that are described in Chapter 7 of this booklet (Asking us topay our share of a bill you have received for covered medical services ordrugs).

1 You will be reimbursed the amount you paid less your normal copaymentfor the vaccine (including administration).

Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’soffice where they give you the vaccine.

1 You will have to pay the pharmacy the amount of your copayment for thevaccine itself.

1 When your doctor gives you the vaccine, you will pay the entire cost forthis service. You can then ask our plan to pay our share of the cost by usingthe procedures described in Chapter 7 of this booklet.

1 Youwill be reimbursed the amount charged by the doctor for administeringthe vaccine.

Section 8.2 You may want to call us at Customer Service before you get avaccination

The rules for coverage of vaccinations are complicated. We are here to help. We recommend thatyou call us first at Customer Service whenever you are planning to get a vaccination. (Phone numbersfor Customer Service are printed on the back cover of this booklet.)

1 We can tell you about how your vaccination is covered by our plan and explain your shareof the cost.

1 We can tell you how to keep your own cost down by using providers and pharmacies in ournetwork.


1 If you are not able to use a network provider and pharmacy, we can tell you what you needto do to get payment from us for our share of the cost.

SECTION 9 Do you have to pay the Part D “late enrollment penalty”?

Section 9.1 What is the Part D “late enrollment penalty”?

Note: If you receive “Extra Help” from Medicare to pay for your prescription drugs, you will notpay a late enrollment penalty.

The late enrollment penalty is an amount that is added to you Part D premium. You may owe a lateenrollment penalty if at any time after your initial enrollment period is over, there is a period of 63days or more in a row when you did not have Part D or other creditable prescription drug coverage.“Creditable prescription drug coverage” is coverage that meets Medicare’s minimum standardssince it is expected to pay, on average, at least as much as Medicare’s standard prescription drugcoverage.) The amount of the penalty depends on how long you waited to enroll in a creditableprescription drug coverage plan any time after the end of your initial enrollment period or howmany full calendar months you went without creditable prescription drug coverage. You will haveto pay this penalty for as long as you have Part D coverage.

When you first enroll in Memorial Hermann Advantage PPO, we let you know the amount of thepenalty. Your late enrollment penalty is considered your plan premium.

Section 9.2 How much is the Part D late enrollment penalty?

Medicare determines the amount of the penalty. Here is how it works:

1 First count the number of full months that you delayed enrolling in a Medicare drug plan,after you were eligible to enroll. Or count the number of full months in which you did nothave creditable prescription drug coverage, if the break in coverage was 63 days or more.The penalty is 1% for every month that you didn’t have creditable coverage. For example,if you go 14 months without coverage, the penalty will be 14%.

1 Then Medicare determines the amount of the average monthly premium for Medicare drugplans in the nation from the previous year. For 2016, this average premium amount is $34.10.

1 To calculate your monthly penalty, you multiply the penalty percentage and the averagemonthly premium and then round it to the nearest 10 cents. In the example here it would be14% times $34.10, which equals $4.77. This rounds to $4.80. This amount would be addedto the monthly premium for someone with a late enrollment penalty.

There are three important things to note about this monthly late enrollment penalty:

1 First, the penaltymay change each year, because the averagemonthly premium can changeeach year. If the national average premium (as determined by Medicare) increases, yourpenalty will increase.


1 Second, you will continue to pay a penalty every month for as long as you are enrolled ina plan that has Medicare Part D drug benefits.

1 Third, if you are under 65 and currently receiving Medicare benefits, the late enrollmentpenalty will reset when you turn 65. After age 65, your late enrollment penalty will be basedonly on the months that you don’t have coverage after your initial enrollment period for aginginto Medicare.

Section 9.3 In some situations, you can enroll late and not have to pay thepenalty

Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you werefirst eligible, sometimes you do not have to pay the late enrollment penalty.

You will not have to pay a penalty for late enrollment if you are in any of these situations:

1 If you already have prescription drug coverage that is expected to pay, on average, at leastas much as Medicare’s standard prescription drug coverage. Medicare calls this “creditabledrug coverage.” Please note:

4 Creditable coverage could include drug coverage from a former employer or union,TRICARE, or the Department of Veterans Affairs. Your insurer or your human resourcesdepartment will tell you each year if your drug coverage is creditable coverage. Thisinformation may be sent to you in a letter or included in a newsletter from the plan. Keepthis information, because you may need it if you join a Medicare drug plan later.

0 Please note: If you receive a “certificate of creditable coverage” when your healthcoverage ends, it may not mean your prescription drug coverage was creditable. Thenotice must state that you had “creditable” prescription drug coverage that expectedto pay as much as Medicare’s standard prescription drug plan pays.

4 The following are not creditable prescription drug coverage: prescription drug discountcards, free clinics, and drug discount websites.

4 For additional information about creditable coverage, please look in your Medicare &You 2016 Handbook or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY/TDD users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7days a week.

1 If you were without creditable coverage, but you were without it for less than 63 days in arow.

1 If you are receiving “Extra Help” from Medicare.

Section 9.4 What can you do if you disagree about your late enrollment penalty?

If you disagree about your late enrollment penalty, you or your representative can ask for a reviewof the decision about your late enrollment penalty. Generally, you must request this review within


60 days from the date on the letter you receive stating you have to pay a late enrollment penalty.Call Customer Service to find out more about how to do this (phone numbers are printed on theback cover of this booklet).

SECTION 10 Do you have to pay an extra Part D amount because ofyour income?

Section 10.1 Who pays an extra Part D amount because of income?

Most people pay a standard monthly Part D premium. However, some people pay an extra amountbecause of their yearly income. If your income is $85,000 or above for an individual (or marriedindividuals filing separately) or $170,000 or above for married couples, you must pay an extraamount directly to the government for your Medicare Part D coverage.

If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a lettertelling you what that extra amount will be and how to pay it. The extra amount will be withheldfrom your Social Security, Railroad Retirement Board, or Office of Personnel Management benefitcheck, nomatter how you usually pay your plan premium, unless your monthly benefit isn’t enoughto cover the extra amount owed. If your benefit check isn’t enough to cover the extra amount, youwill get a bill from Medicare. You must pay the extra amount to the government. It cannot bepaid with your monthly plan premium.

Section 10.2 How much is the extra Part D amount?

If your modified adjusted gross income (MAGI) as reported on your IRS tax return is above acertain amount, you will pay an extra amount in addition to your monthly plan premium.

The chart below shows the extra amount based on your income.

This is themonthly costof your extra Part Damount (to be paid inaddition to your planpremium)

If you filed a joint taxreturn and your incomein 2015 was:

If you weremarried but filed aseparate tax returnand your income in2015 was:

If you filed anindividual tax returnand your incomein 2015 was:

$0Equal to or less than$170,000

Equal to or less than$85,000

Equal to or less than$85,000

$12.70Greater than $170,000and less than or equal to$214,000

Greater than $85,000and less than or equal to$107,000


This is themonthly costof your extra Part Damount (to be paid inaddition to your planpremium)

If you filed a joint taxreturn and your incomein 2015 was:

If you weremarried but filed aseparate tax returnand your income in2015 was:

If you filed anindividual tax returnand your incomein 2015 was:




Greater than $85,000and less than orequal to $129,000


$72.90Greater than $428,000Greater than$129,000

Greater than $214,000

Section 10.3 What can you do if you disagree about paying an extra Part Damount?

If you disagree about paying an extra amount because of your income, you can ask Social Securityto review the decision. To find out more about how to do this, contact Social Security at1-800-772-1213 (TTY/TDD 1-800-325-0778).

Section 10.4 What happens if you do not pay the extra Part D amount?

The extra amount is paid directly to the government (not your Medicare plan) for your MedicarePart D coverage. If you are required to pay the extra amount and you do not pay it, you will bedisenrolled from the plan and lose prescription drug coverage.


CHAPTER 7Asking us to pay our

share of a bill you havereceived for covered

medical services or drugs

Chapter 7. Asking us to pay our share of a bill you have received forcovered medical services or drugs

SECTION 1 Situations in which you should ask us to pay our share of thecost of your covered services or drugs ........................................... 132

Section 1.1 If you pay our plan’s share of the cost of your covered services or drugs,or if you receive a bill, you can ask us for payment ..................................... 132

SECTION 2 How to ask us to pay you back or to pay a bill you havereceived ...............................................................................................134

Section 2.1 How and where to send us your request for payment ................................... 134

SECTION 3 We will consider your request for payment and say yes or no ..... 135

Section 3.1 We check to see whether we should cover the service or drug and howmuch we owe ................................................................................................ 135

Section 3.2 If we tell you that we will not pay for all or part of the medical care or drug,you can make an appeal ................................................................................ 135

SECTION 4 Other situations in which you should save your receipts and sendcopies to us ........................................................................................136

Section 4.1 In some cases, you should send copies of your receipts to us to help us trackyour out-of-pocket drug costs ....................................................................... 136

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 131Chapter 7. Asking us to pay our share of a bill you have received for covered medicalservices or drugs

SECTION 1 Situations in which you should ask us to pay our share ofthe cost of your covered services or drugs

Section 1.1 If you pay our plan’s share of the cost of your covered services ordrugs, or if you receive a bill, you can ask us for payment

Sometimes when you get medical care or a prescription drug, you may need to pay the full costright away. Other times, youmay find that you have paid more than you expected under the coveragerules of the plan. In either case, you can ask our plan to pay you back (paying you back is oftencalled “reimbursing” you). It is your right to be paid back by our plan whenever you’ve paid morethan your share of the cost for medical services or drugs that are covered by our plan.

There may also be times when you get a bill from a provider for the full cost of medical care youhave received. In many cases, you should send this bill to us instead of paying it. We will look atthe bill and decide whether the services should be covered. If we decide they should be covered,we will pay the provider directly.

Here are examples of situations in which you may need to ask our plan to pay you back or to paya bill you have received:

1. When you’ve received medical care from a provider who is not in our plan’s network

When you received care from a provider who is not part of our network, you are onlyresponsible for paying your share of the cost, not for the entire cost. (Your share of the costmay be higher for an out-of-network provider than for a network provider.) You should askthe provider to bill the plan for our share of the cost.

1 If you pay the entire amount yourself at the time you receive the care, you need to ask usto pay you back for our share of the cost. Send us the bill, along with documentation ofany payments you have made.

1 At times you may get a bill from the provider asking for payment that you think you donot owe. Send us this bill, along with documentation of any payments you have alreadymade.

4 If the provider is owed anything, we will pay the provider directly.

4 If you have already paid more than your share of the cost of the service, we willdetermine how much you owed and pay you back for our share of the cost.

1 Please note:While you can get your care from an out-of-network provider, the providermust be eligible to participate in Medicare. Except for emergency care, we cannot pay aprovider who is not eligible to participate in Medicare. If the provider is not eligible toparticipate inMedicare, you will be responsible for the full cost of the services you receive.

2. When a network provider sends you a bill you think you should not pay

Network providers should always bill the plan directly, and ask you only for your share ofthe cost. But sometimes they make mistakes, and ask you to pay more than your share.


1 You only have to pay your cost-sharing amount when you get services covered by ourplan.We do not allow providers to add additional separate charges, called “balance billing.”This protection (that you never pay more than your cost-sharing amount) applies even ifwe pay the provider less than the provider charges for a service and even if there is adispute and we don’t pay certain provider charges. For more information about “balancebilling,” go to Chapter 4, Section 1.3.

1 Whenever you get a bill from a network provider that you think is more than you shouldpay, send us the bill. We will contact the provider directly and resolve the billing problem.

1 If you have already paid a bill to a network provider, but you feel that you paid too much,send us the bill along with documentation of any payment you have made and ask us topay you back the difference between the amount you paid and the amount you owed underthe plan.

3. If you are retroactively enrolled in our plan.

Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the firstday of their enrollment has already passed. The enrollment date may even have occurred lastyear.)

If you were retroactively enrolled in our plan and you paid out-of-pocket for any of yourcovered services or drugs after your enrollment date, you can ask us to pay you back for ourshare of the costs. You will need to submit paperwork for us to handle the reimbursement.

Please call Customer Service for additional information about how to ask us to pay you backand deadlines for making your request. (Phone numbers for Customer Service are printed onthe back cover of this booklet.)

4. When you use an out-of-network pharmacy to get a prescription filled

If you go to an out-of-network pharmacy and try to use your membership card to fill aprescription, the pharmacy may not be able to submit the claim directly to us. When thathappens, you will have to pay the full cost of your prescription. (We cover prescriptions filledat out-of-network pharmacies only in a few special situations. Please go to Chapter 5, Section2.5 to learn more.)

Save your receipt and send a copy to us when you ask us to pay you back for our share ofthe cost.

5. When you pay the full cost for a prescription because you don’t have your planmembership card with you

If you do not have your plan membership card with you, you can ask the pharmacy to callthe plan or to look up your plan enrollment information. However, if the pharmacy cannotget the enrollment information they need right away, you may need to pay the full cost ofthe prescription yourself.

Save your receipt and send a copy to us when you ask us to pay you back for our share ofthe cost.


6. When you pay the full cost for a prescription in other situations

You may pay the full cost of the prescription because you find that the drug is not coveredfor some reason.

1 For example, the drug may not be on the plan’s List of Covered Drugs (Formulary); or itcould have a requirement or restriction that you didn’t know about or don’t think shouldapply to you. If you decide to get the drug immediately, you may need to pay the full costfor it.

1 Save your receipt and send a copy to us when you ask us to pay you back. In somesituations, we may need to get more information from your doctor in order to pay youback for our share of the cost.

All of the examples above are types of coverage decisions. This means that if we deny your requestfor payment, you can appeal our decision. Chapter 9 of this booklet (What to do if you have aproblem or complaint (coverage decisions, appeals, complaints)) has information about how tomake an appeal.

SECTION 2 How to ask us to pay you back or to pay a bill you havereceived

Section 2.1 How and where to send us your request for payment

Send us your request for payment, along with your bill and documentation of any payment youhave made. It’s a good idea to make a copy of your bill and receipts for your records.

To make sure you are giving us all the information we need to make a decision, you can fill outour claim form to make your request for payment.

1 You don’t have to use the form, but it will help us process the information faster.

1 Either download a copy of the form from our website(healthplan.memorialhermann.org/medicare) or call Customer Service and ask for the form.(Phone numbers for Customer Service are printed on the back cover of this booklet.)

Mail your request for payment together with any bills or receipts to us at this address:

Memorial Hermann Advantage PPO ClaimsP.O. Box 226526

Dallas, TX 75222-6526

Mail your request for Part D prescription drugs, together with any bills or receipts to us at thisaddress:

EnvisionAttn: Member Reimbursement Department


2181 E. Aurora Road, Suite 201Twinsburg, OH 44087

You must submit your claim to us within one (1) year of the date you received the service, item,or drug.

Contact Customer Service if you have any questions (phone numbers are printed on the back coverof this booklet). If you don’t know what you should have paid, or you receive bills and you don’tknow what to do about those bills, we can help. You can also call if you want to give us moreinformation about a request for payment you have already sent to us.

SECTION 3 We will consider your request for payment and say yes orno

Section 3.1 We check to see whether we should cover the service or drug andhow much we owe

When we receive your request for payment, we will let you know if we need any additionalinformation from you. Otherwise, we will consider your request and make a coverage decision.

1 If we decide that the medical care or drug is covered and you followed all the rules for gettingthe care or drug, we will pay for our share of the cost. If you have already paid for the serviceor drug, we will mail your reimbursement of our share of the cost to you. If you have notpaid for the service or drug yet, we will mail the payment directly to the provider. (Chapter 3explains the rules you need to follow for getting your medical services covered. Chapter 5explains the rules you need to follow for getting your Part D prescription drugs covered.)

1 If we decide that the medical care or drug is not covered, or you did not follow all the rules,we will not pay for our share of the cost. Instead, we will send you a letter that explains thereasons why we are not sending the payment you have requested and your rights to appealthat decision.

Section 3.2 If we tell you that we will not pay for all or part of the medical careor drug, you can make an appeal

If you think we have made a mistake in turning down your request for payment or you don’t agreewith the amount we are paying, you can make an appeal. If you make an appeal, it means you areasking us to change the decision we made when we turned down your request for payment.

For the details on how to make this appeal, go to Chapter 9 of this booklet (What to do if you havea problem or complaint (coverage decisions, appeals, complaints)). The appeals process is a formalprocess with detailed procedures and important deadlines. If making an appeal is new to you, youwill find it helpful to start by reading Section 4 of Chapter 9. Section 4 is an introductory section


that explains the process for coverage decisions and appeals and gives definitions of terms such as“appeal.” Then after you have read Section 4, you can go to the section in Chapter 9 that tells whatto do for your situation:

1 If you want to make an appeal about getting paid back for a medical service, go to Section 5.3in Chapter 9.

1 If you want to make an appeal about getting paid back for a drug, go to Section 6.5 ofChapter 9.

SECTION 4 Other situations in which you should save your receiptsand send copies to us

Section 4.1 In some cases, you should send copies of your receipts to us tohelp us track your out-of-pocket drug costs

There are some situations when you should let us know about payments you have made for yourdrugs. In these cases, you are not asking us for payment. Instead, you are telling us about yourpayments so that we can calculate your out-of-pocket costs correctly. This may help you to qualifyfor the Catastrophic Coverage Stage more quickly.

Here are two situations when you should send us copies of receipts to let us know about paymentsyou have made for your drugs:

1. When you buy the drug for a price that is lower than our price

Sometimes when you are in the Deductible Stage and Coverage Gap Stage you can buy yourdrug at a network pharmacy for a price that is lower than our price.1 For example, a pharmacy might offer a special price on the drug. Or you may have a discountcard that is outside our benefit that offers a lower price.

1 Unless special conditions apply, you must use a network pharmacy in these situations andyour drug must be on our Drug List.

1 Save your receipt and send a copy to us so that we can have your out-of-pocket expensescount toward qualifying you for the Catastrophic Coverage Stage.

1 Please note: If you are in the Deductible Stage and Coverage Gap Stage, we may not payfor any share of these drug costs. But sending a copy of the receipt allows us to calculateyour out-of-pocket costs correctly and may help you qualify for the Catastrophic CoverageStage more quickly.

2. When you get a drug through a patient assistance program offered by a drugmanufacturer

Some members are enrolled in a patient assistance program offered by a drug manufacturer thatis outside the plan benefits. If you get any drugs through a program offered by a drugmanufacturer, you may pay a copayment to the patient assistance program.


1 Save your receipt and send a copy to us so that we can have your out-of-pocket expensescount toward qualifying you for the Catastrophic Coverage Stage.

1 Please note: Because you are getting your drug through the patient assistance program andnot through the plan’s benefits, we will not pay for any share of these drug costs. But sendinga copy of the receipt allows us to calculate your out-of-pocket costs correctly and may helpyou qualify for the Catastrophic Coverage Stage more quickly.

Since you are not asking for payment in the two cases described above, these situations are notconsidered coverage decisions. Therefore, you cannot make an appeal if you disagree with ourdecision.


CHAPTER 8Your rights andresponsibilities

Chapter 8. Your rights and responsibilities

SECTION 1 Our plan must honor your rights as a member of the plan ........... 140

Section 1.1 We must provide information in a way that works for you (in languagesother than English, in Braille, in large print, or other alternate formats,etc.) ............................................................................................................... 140

Section 1.2 We must treat you with fairness and respect at all times .............................. 140

Section 1.3 We must ensure that you get timely access to your covered services anddrugs ............................................................................................................. 141

Section 1.4 We must protect the privacy of your personal health information ............... 141

Section 1.5 Wemust give you information about the plan, its network of providers, andyour covered services ................................................................................... 142

Section 1.6 We must support your right to make decisions about your care ................... 143

Section 1.7 You have the right to make complaints and to ask us to reconsider decisionswe have made ............................................................................................... 145

Section 1.8 What can you do if you believe you are being treated unfairly or your rightsare not being respected? ............................................................................... 145

Section 1.9 How to get more information about your rights ........................................... 146

SECTION 2 You have some responsibilities as a member of the plan ............. 146

Section 2.1 What are your responsibilities? .................................................................... 146

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 139Chapter 8. Your rights and responsibilities

SECTION 1 Our plan must honor your rights as a member of the plan

Section 1.1 We must provide information in a way that works for you (inlanguages other than English, in Braille, in large print, or otheralternate formats, etc.)

To get information from us in a way that works for you, please call Customer Service (phonenumbers are printed on the back cover of this booklet).

Our plan has people and free language interpreter services available to answer questions fromnon-English speaking members.We can also give you information in Braille, in large print, or otheralternate formats if you need it. If you are eligible for Medicare because of a disability, we arerequired to give you information about the plan’s benefits that is accessible and appropriate foryou. To get information from us in a way that works for you, please call Customer Service (phonenumbers are printed on the back cover of this booklet).

If you have any trouble getting information from our plan because of problems related to languageor a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7days a week, and tell them that you want to file a complaint. TTY/TDD users call 1-877-486-2048.

Para obtener información de una forma que pueda comprenderla, comuníquese con el Servicio deAtención al Cliente (los números telefónicos aparecen en la contraportada de este cuadernillo).

Nuestro plan cuenta con personal y servicios de interpretación gratuitos disponibles para responderlas preguntas de los miembros que no hablen inglés. También podemos brindarle información enbraille, textos con letras grandes u otros formatos alternativos si lo requiere. Si usted es elegiblepara Medicare por tener una discapacidad, tenemos la obligación de proporcionarle informaciónsobre los beneficios del plan en forma accesible y adecuada para usted. Para obtener informaciónde una forma que pueda comprenderla, comuníquese con el Servicio de Atención al Cliente (losnúmeros telefónicos aparecen en la contraportada de este cuadernillo).

Si tiene algún inconveniente para obtener información de nuestro plan por problemas relacionadoscon el idioma o con una incapacidad, llame a Medicare al 1-800-MEDICARE (1-800-633-4227),las 24 horas del día, los 7 días de la semana e informe que desea presentar una queja. Los usuariosde TTY/TDD pueden llamar al 1-877-486-2048.

Section 1.2 We must treat you with fairness and respect at all times

Our plan must obey laws that protect you from discrimination or unfair treatment.We do notdiscriminate based on a person’s race, ethnicity, national origin, religion, gender, age, mental orphysical disability, health status, claims experience, medical history, genetic information, evidenceof insurability, or geographic location within the service area.


If you want more information or have concerns about discrimination or unfair treatment, pleasecall the Department of Health and Human Services’Office for Civil Rights 1-800-368-1019 (TTY/TDD 1-800-537-7697) or your local Office for Civil Rights.

If you have a disability and need help with access to care, please call us at Customer Service (phonenumbers are printed on the back cover of this booklet). If you have a complaint, such as a problemwith wheelchair access, Customer Service can help.

Section 1.3 Wemust ensure that you get timely access to your covered servicesand drugs

You have the right to choose a provider in the plan’s network. Call Customer Service to learn whichdoctors are accepting new patients (phone numbers are printed on the back cover of this booklet).You also have the right to go to a women’s health specialist (such as a gynecologist) without areferral and still pay the in-network cost-sharing amount.

As a plan member, you have the right to get appointments and covered services from your providerswithin a reasonable amount of time. This includes the right to get timely services from specialistswhen you need that care. You also have the right to get your prescriptions filled or refilled at anyof our network pharmacies without long delays.

If you think that you are not getting your medical care or Part D drugs within a reasonable amountof time, Chapter 9, Section 10 of this booklet tells what you can do. (If we have denied coveragefor your medical care or drugs and you don’t agree with our decision, Chapter 9, Section 4 tellswhat you can do.)

Section 1.4 We must protect the privacy of your personal health information

Federal and state laws protect the privacy of your medical records and personal health information.We protect your personal health information as required by these laws.

1 Your “personal health information” includes the personal information you gave us when youenrolled in this plan as well as your medical records and other medical and health information.

1 The laws that protect your privacy give you rights related to getting information and controllinghow your health information is used.We give you a written notice, called a “Notice of PrivacyPractice,” that tells about these rights and explains how we protect the privacy of your healthinformation.

How do we protect the privacy of your health information?1 We make sure that unauthorized people don’t see or change your records.

1 In most situations, if we give your health information to anyone who isn’t providing yourcare or paying for your care,we are required to get written permission from you first.Writtenpermission can be given by you or by someone you have given legal power to make decisionsfor you.


1 There are certain exceptions that do not require us to get your written permission first. Theseexceptions are allowed or required by law.

4 For example, we are required to release health information to government agencies thatare checking on quality of care.

4 Because you are a member of our plan throughMedicare, we are required to giveMedicareyour health information including information about your Part D prescription drugs. IfMedicare releases your information for research or other uses, this will be done accordingto Federal statutes and regulations.

You can see the information in your records and know how it has been shared withothersYou have the right to look at your medical records held at the plan, and to get a copy of your records.We are allowed to charge you a fee for making copies. You also have the right to ask us to makeadditions or corrections to your medical records. If you ask us to do this, we will work with yourhealth care provider to decide whether the changes should be made.

You have the right to know how your health information has been shared with others for anypurposes that are not routine.

If you have questions or concerns about the privacy of your personal health information, pleasecall Customer Service (phone numbers are printed on the back cover of this booklet).

Section 1.5 We must give you information about the plan, its network ofproviders, and your covered services

As a member of Memorial Hermann Advantage PPO, you have the right to get several kinds ofinformation from us. (As explained above in Section 1.1, you have the right to get information fromus in a way that works for you. This includes getting the information in languages other than Englishand in large print or other alternate formats.)

If you want any of the following kinds of information, please call Customer Service (phone numbersare printed on the back cover of this booklet):

1 Information about our plan. This includes, for example, information about the plan’sfinancial condition. It also includes information about the number of appeals made bymembersand the plan’s performance ratings, including how it has been rated by plan members andhow it compares to other Medicare health plans.

1 Information about our network providers including our network pharmacies.

4 For example, you have the right to get information from us about the qualifications of theproviders and pharmacies in our network and how we pay the providers in our network.

4 For a list of the providers in the plan’s network, see the Provider Directory.

4 For a list of the pharmacies in the plan’s network, see the Pharmacy Directory.


4 For more detailed information about our providers or pharmacies, you can call CustomerService (phone numbers are printed on the back cover of this booklet) or visit our websiteat healthplan.memorialhermann.org/medicare.

1 Information about your coverage and the rules you must follow when using yourcoverage.

4 In Chapters 3 and 4 of this booklet, we explain what medical services are covered for you,any restrictions to your coverage, and what rules you must follow to get your coveredmedical services.

4 To get the details on your Part D prescription drug coverage, see Chapters 5 and 6 of thisbooklet plus the plan’s List of Covered Drugs (Formulary). These chapters, together withthe List of Covered Drugs (Formulary), tell you what drugs are covered and explain therules you must follow and the restrictions to your coverage for certain drugs.

4 If you have questions about the rules or restrictions, please call Customer Service (phonenumbers are printed on the back cover of this booklet).

1 Information about why something is not covered and what you can do about it.

4 If a medical service or Part D drug is not covered for you, or if your coverage is restrictedin some way, you can ask us for a written explanation. You have the right to thisexplanation even if you received the medical service or drug from an out-of-networkprovider or pharmacy.

4 If you are not happy or if you disagree with a decision we make about what medical careor Part D drug is covered for you, you have the right to ask us to change the decision. Youcan ask us to change the decision by making an appeal. For details on what to do ifsomething is not covered for you in the way you think it should be covered, see Chapter9 of this booklet. It gives you the details about how to make an appeal if you want us tochange our decision. (Chapter 9 also tells about how to make a complaint about qualityof care, waiting times, and other concerns.)

4 If you want to ask our plan to pay our share of a bill you have received for medical careor a Part D prescription drug, see Chapter 7 of this booklet.

Section 1.6 We must support your right to make decisions about your care

You have the right to know your treatment options and participate in decisions aboutyour health careYou have the right to get full information from your doctors and other health care providers whenyou go for medical care. Your providers must explain your medical condition and your treatmentchoices in a way that you can understand.

You also have the right to participate fully in decisions about your health care. To help you makedecisions with your doctors about what treatment is best for you, your rights include the following:


1 To know about all of your choices. This means that you have the right to be told about allof the treatment options that are recommended for your condition, no matter what they costor whether they are covered by our plan. It also includes being told about programs our planoffers to help members manage their medications and use drugs safely.

1 To know about the risks. You have the right to be told about any risks involved in yourcare. You must be told in advance if any proposed medical care or treatment is part of aresearch experiment. You always have the choice to refuse any experimental treatments.

1 The right to say “no.” You have the right to refuse any recommended treatment. This includesthe right to leave a hospital or other medical facility, even if your doctor advises you not toleave. You also have the right to stop taking your medication. Of course, if you refusetreatment or stop taking medication, you accept full responsibility for what happens to yourbody as a result.

1 To receive an explanation if you are denied coverage for care. You have the right toreceive an explanation from us if a provider has denied care that you believe you shouldreceive. To receive this explanation, you will need to ask us for a coverage decision. Chapter 9of this booklet tells how to ask the plan for a coverage decision.

You have the right to give instructions about what is to be done if you are not ableto make medical decisions for yourselfSometimes people become unable to make health care decisions for themselves due to accidentsor serious illness. You have the right to say what you want to happen if you are in this situation.This means that, if you want to, you can:

1 Fill out a written form to give someone the legal authority to make medical decisions foryou if you ever become unable to make decisions for yourself.

1 Give your doctors written instructions about how you want them to handle your medicalcare if you become unable to make decisions for yourself.

The legal documents that you can use to give your directions in advance in these situations arecalled “advance directives.” There are different types of advance directives and different namesfor them. Documents called “living will” and “power of attorney for health care” are examplesof advance directives.

If you want to use an “advance directive” to give your instructions, here is what to do:

1 Get the form. If you want to have an advance directive, you can get a form from your lawyer,from a social worker, or from some office supply stores. You can sometimes get advancedirective forms from organizations that give people information about Medicare.

1 Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legaldocument. You should consider having a lawyer help you prepare it.

1 Give copies to appropriate people. You should give a copy of the form to your doctor andto the person you name on the form as the one to make decisions for you if you can’t. Youmay want to give copies to close friends or family members as well. Be sure to keep a copyat home.


If you know ahead of time that you are going to be hospitalized, and you have signed an advancedirective, take a copy with you to the hospital.

1 If you are admitted to the hospital, they will ask you whether you have signed an advancedirective form and whether you have it with you.

1 If you have not signed an advance directive form, the hospital has forms available and willask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (includingwhether you want to sign one if you are in the hospital). According to law, no one can deny youcare or discriminate against you based on whether or not you have signed an advance directive.

What if your instructions are not followed?If you have signed an advance directive, and you believe that a doctor or hospital did not followthe instructions in it, you may file a complaint with Texas Department of State Health Services.

Section 1.7 You have the right to make complaints and to ask us to reconsiderdecisions we have made

If you have any problems or concerns about your covered services or care, Chapter 9 of this booklettells what you can do. It gives the details about how to deal with all types of problems and complaints.What you need to do to follow up on a problem or concern depends on the situation. You mightneed to ask our plan to make a coverage decision for you, make an appeal to us to change a coveragedecision, or make a complaint. Whatever you do – ask for a coverage decision, make an appeal, ormake a complaint – we are required to treat you fairly.

You have the right to get a summary of information about the appeals and complaints that othermembers have filed against our plan in the past. To get this information, please call CustomerService (phone numbers are printed on the back cover of this booklet).

Section 1.8 What can you do if you believe you are being treated unfairly oryour rights are not being respected?

If it is about discrimination, call the Office for Civil RightsIf you believe you have been treated unfairly or your rights have not been respected due to yourrace, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you shouldcall the Department of Health and Human Services’Office for Civil Rights at 1-800-368-1019 orTTY/TDD 1-800-537-7697, or call your local Office for Civil Rights.

Is it about something else?If you believe you have been treated unfairly or your rights have not been respected, and it’s notabout discrimination, you can get help dealing with the problem you are having:

1 You can call Customer Service (phone numbers are printed on the back cover of this booklet).


1 You can call the State Health Insurance Assistance Program. For details about thisorganization and how to contact it, go to Chapter 2, Section 3.

1 Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 daysa week. TTY/TDD users should call 1-877-486-2048.

Section 1.9 How to get more information about your rights

There are several places where you can get more information about your rights:


1 You can call the State Health Insurance Assistance Program. For details about thisorganization and how to contact it, go to Chapter 2, Section 3.

1 You can contactMedicare.

4 You can visit the Medicare website to read or download the publication “Your MedicareRights & Protections.” (The publication is available at:http://www.medicare.gov/Pubs/pdf/11534.pdf.)

4 Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.TTY/TDD users should call 1-877-486-2048.

SECTION 2 You have some responsibilities as a member of the plan

Section 2.1 What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions, pleasecall Customer Service (phone numbers are printed on the back cover of this booklet). We’re hereto help.

1 Get familiar with your covered services and the rules you must follow to get thesecovered services. Use this Evidence of Coverage booklet to learn what is covered for youand the rules you need to follow to get your covered services.

4 Chapters 3 and 4 give the details about your medical services, including what is covered,what is not covered, rules to follow, and what you pay.

4 Chapters 5 and 6 give the details about your coverage for Part D prescription drugs.

1 If you have any other health insurance coverage or prescription drug coverage in addition toour plan, you are required to tell us. Please call Customer Service to let us know (phonenumbers are printed on the back cover of this booklet).


We are required to follow rules set by Medicare to make sure that you are using all ofyour coverage in combination when you get your covered services from our plan. This iscalled “coordination of benefits” because it involves coordinating the health and drugbenefits you get from our plan with any other health and drug benefits available to you.We’ll help you coordinate your benefits. (For more information about coordination ofbenefits, go to Chapter 1, Section 7.)

4

1 Tell your doctor and other health care providers that you are enrolled in our plan. Showyour plan membership card whenever you get your medical care or Part D prescription drugs.

1 Help your doctors and other providers help you by giving them information, askingquestions, and following through on your care.

4 To help your doctors and other health providers give you the best care, learn as much asyou are able to about your health problems and give them the information they need aboutyou and your health. Follow the treatment plans and instructions that you and your doctorsagree upon.

4 Make sure your doctors know all of the drugs you are taking, including over-the-counterdrugs, vitamins, and supplements.

4 If you have any questions, be sure to ask. Your doctors and other health care providersare supposed to explain things in a way you can understand. If you ask a question andyou don’t understand the answer you are given, ask again.

1 Be considerate.We expect all our members to respect the rights of other patients. We alsoexpect you to act in a way that helps the smooth running of your doctor’s office, hospitals,and other offices.

1 Pay what you owe. As a plan member, you are responsible for these payments:

4 In order to be eligible for our plan, you must have Medicare Part A and Medicare Part B.For that reason, some plan members must pay a premium for Medicare Part A and mostplan members must pay a premium for Medicare Part B to remain a member of the plan.

4 For most of your medical services or drugs covered by the plan, you must pay your shareof the cost when you get the service or drug. This will be a copayment (a fixed amount)or coinsurance (a percentage of the total cost). Chapter 4 tells what you must pay for yourmedical services. Chapter 6 tells what you must pay for your Part D prescription drugs.

1 If you get any medical services or drugs that are not covered by our plan or by otherinsurance you may have, you must pay the full cost.

1 If you disagree with our decision to deny coverage for a service or drug, you can makean appeal. Please see Chapter 9 of this booklet for information about how to make anappeal.

4 If you are required to pay a late enrollment penalty, you must pay the penalty to the plan.

4 If you are required to pay the extra amount for Part D because of your yearly income, youmust pay the extra amount directly to the government to remain a member of the plan.


1 Tell us if you move. If you are going to move, it’s important to tell us right away. CallCustomer Service (phone numbers are printed on the back cover of this booklet).

4 If you move outside of our plan service area, you cannot remain a member of ourplan. (Chapter 1 tells about our service area.) We can help you figure out whether youare moving outside our service area. If you are leaving our service area, you will have aSpecial Enrollment Period when you can join any Medicare plan available in your newarea. We can let you know if we have a plan in your new area.

4 If you move within our service area, we still need to know so we can keep yourmembership record up to date and know how to contact you.

4 If you move, it is also important to tell Social Security (or the Railroad Retirement Board).You can find phone numbers and contact information for these organizations in Chapter2.

1 Call Customer Service for help if you have questions or concerns.We also welcome anysuggestions you may have for improving our plan.

4 Phone numbers and calling hours for Customer Service are printed on the back cover ofthis booklet.

4 Formore information on how to reach us, including our mailing address, please see Chapter2.


CHAPTER 9What to do if you have a

problem or complaint(coverage decisions,appeals, complaints)

Chapter 9. What to do if you have a problem or complaint (coveragedecisions, appeals, complaints)

BACKGROUND ...........................................................................................................153


Section 1.1 What to do if you have a problem or concern .............................................. 153

Section 1.2 What about the legal terms? ......................................................................... 153

SECTION 2 You can get help from government organizations that are notconnected with us ..............................................................................153

Section 2.1 Where to get more information and personalized assistance ........................ 153

SECTION 3 To deal with your problem, which process should you use? ........ 154

Section 3.1 Should you use the process for coverage decisions and appeals? Or shouldyou use the process for making complaints? ................................................ 154

COVERAGE DECISIONS AND APPEALS .................................................................155

SECTION 4 A guide to the basics of coverage decisions and appeals ............ 155

Section 4.1 Asking for coverage decisions and making appeals: the big picture ............ 155

Section 4.2 How to get help when you are asking for a coverage decision or making anappeal ............................................................................................................ 156

Section 4.3 Which section of this chapter gives the details for your situation? .............. 157

SECTION 5 Your medical care: How to ask for a coverage decision or makean appeal .............................................................................................157

Section 5.1 This section tells what to do if you have problems getting coverage formedical care or if you want us to pay you back for our share of the cost ofyour care ....................................................................................................... 157

Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan toauthorize or provide the medical care coverage you want) .......................... 159

Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review ofa medical care coverage decision made by our plan) ................................... 162

Section 5.4 Step-by-step: How a Level 2 Appeal is done ............................................... 164

Section 5.5 What if you are asking us to pay you for our share of a bill you have receivedfor medical care? .......................................................................................... 166

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 150Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals,complaints)

SECTION 6 Your Part D prescription drugs: How to ask for a coverage decisionor make an appeal ..............................................................................167

Section 6.1 This section tells you what to do if you have problems getting a Part D drugor you want us to pay you back for a Part D drug ........................................ 167

Section 6.2 What is an exception? ................................................................................... 169

Section 6.3 Important things to know about asking for exceptions ................................. 170

Section 6.4 Step-by-step: How to ask for a coverage decision, including anexception ....................................................................................................... 171

Section 6.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review ofa coverage decision made by our plan) ........................................................ 174

Section 6.6 Step-by-step: How to make a Level 2 Appeal .............................................. 176

SECTION 7 How to ask us to cover a longer inpatient hospital stay if you thinkthe doctor is discharging you too soon .......................................... 178

Section 7.1 During your inpatient hospital stay, you will get a written notice fromMedicare that tells about your rights ............................................................ 178

Section 7.2 Step-by-step: How to make a Level 1 Appeal to change your hospitaldischarge date ............................................................................................... 180

Section 7.3 Step-by-step: How to make a Level 2 Appeal to change your hospitaldischarge date ............................................................................................... 182

Section 7.4 What if you miss the deadline for making your Level 1 Appeal? ................ 183

SECTION 8 How to ask us to keep covering certain medical services if youthink your coverage is ending too soon .......................................... 186

Section 8.1 This section is about three services only:Home health care, skilled nursingfacility care, and Comprehensive Outpatient Rehabilitation Facility (CORF)services ......................................................................................................... 186

Section 8.2 We will tell you in advance when your coverage will be ending ................. 186

Section 8.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover yourcare for a longer time .................................................................................... 187

Section 8.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover yourcare for a longer time .................................................................................... 189

Section 8.5 What if you miss the deadline for making your Level 1 Appeal? ................ 190


SECTION 9 Taking your appeal to Level 3 and beyond ...................................... 193

Section 9.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals .......................... 193

Section 9.2 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals ................................. 194

MAKING COMPLAINTS .............................................................................................195

SECTION 10 How to make a complaint about quality of care, waiting times,customer service, or other concerns ............................................... 195

Section 10.1 What kinds of problems are handled by the complaint process? ................. 196

Section 10.2 The formal name for “making a complaint” is “filing a grievance” ............. 197

Section 10.3 Step-by-step: Making a complaint ................................................................ 197

Section 10.4 You can also make complaints about quality of care to the QualityImprovement Organization ........................................................................... 199

Section 10.5 You can also tell Medicare about your complaint ........................................ 199


BACKGROUND


Section 1.1 What to do if you have a problem or concern

This chapter explains two types of processes for handling problems and concerns:

1 For some types of problems, you need to use the process for coverage decisions and appeals.

1 For other types of problems, you need to use the process for making complaints.

Both of these processes have been approved by Medicare. To ensure fairness and prompt handlingof your problems, each process has a set of rules, procedures, and deadlines that must be followedby us and by you.

Which one do you use? That depends on the type of problem you are having. The guide in Section 3will help you identify the right process to use.

Section 1.2 What about the legal terms?

There are technical legal terms for some of the rules, procedures, and types of deadlines explainedin this chapter. Many of these terms are unfamiliar to most people and can be hard to understand.

To keep things simple, this chapter explains the legal rules and procedures using simpler words inplace of certain legal terms. For example, this chapter generally says “making a complaint” ratherthan “filing a grievance,” “coverage decision” rather than “organization determination” or “coveragedetermination,” and “Independent Review Organization” instead of “Independent Review Entity.”It also uses abbreviations as little as possible.

However, it can be helpful – and sometimes quite important – for you to know the correct legalterms for the situation you are in. Knowing which terms to use will help you communicate moreclearly and accurately when you are dealing with your problem and get the right help or informationfor your situation. To help you know which terms to use, we include legal terms when we give thedetails for handling specific types of situations.

SECTION 2 You can get help from government organizations that arenot connected with us

Section 2.1 Where to get more information and personalized assistance

Sometimes it can be confusing to start or follow through the process for dealing with a problem.This can be especially true if you do not feel well or have limited energy. Other times, you maynot have the knowledge you need to take the next step.


Get help from an independent government organizationWe are always available to help you. But in some situations you may also want help or guidancefrom someone who is not connected with us. You can always contact your State Health InsuranceAssistance Program (SHIP). This government program has trained counselors in every state. Theprogram is not connected with us or with any insurance company or health plan. The counselorsat this program can help you understand which process you should use to handle a problem youare having. They can also answer your questions, give you more information, and offer guidanceon what to do.

The services of SHIP counselors are free. You will find phone numbers in Chapter 2, Section 3 ofthis booklet.

You can also get help and information from MedicareFor more information and help in handling a problem, you can also contact Medicare. Here are twoways to get information directly from Medicare:

1 You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.

1 You can visit the Medicare website (http://www.medicare.gov).

SECTION 3 To deal with your problem, which process should you use?

Section 3.1 Should you use the process for coverage decisions and appeals?Or should you use the process for making complaints?

If you have a problem or concern, you only need to read the parts of this chapter that apply to yoursituation. The guide that follows will help.

To figure out which part of this chapter will help with your specific problem or concern, STARTHERE

Is your problem or concern about your benefits or coverage?(This includes problems about whether particular medical care or prescription drugs are coveredor not, the way in which they are covered, and problems related to payment for medical care orprescription drugs.)

Yes.My problem is about benefits or coverage.Go on to the next section of this chapter, Section 4, “A guide to the basics of coveragedecisions and appeals.”

No.My problem is not about benefits or coverage.Skip ahead to Section 10 at the end of this chapter: “How to make a complaint aboutquality of care, waiting times, customer service or other concerns.”


COVERAGE DECISIONS AND APPEALS

SECTION 4 A guide to the basics of coverage decisions and appeals

Section 4.1 Asking for coverage decisions andmaking appeals: the big picture

The process for coverage decisions and appeals deals with problems related to your benefits andcoverage for medical services and prescription drugs, including problems related to payment. Thisis the process you use for issues such as whether something is covered or not and the way in whichsomething is covered.

Asking for coverage decisionsA coverage decision is a decision we make about your benefits and coverage or about the amountwe will pay for your medical services or drugs. For example, your plan network doctor makes a(favorable) coverage decision for you whenever you receive medical care from him or her or ifyour network doctor refers you to a medical specialist. You or your doctor can also contact us andask for a coverage decision if your doctor is unsure whether we will cover a particular medicalservice or refuses to provide medical care you think that you need. In other words, if you want toknow if we will cover a medical service before you receive it, you can ask us to make a coveragedecision for you.

We are making a coverage decision for you whenever we decide what is covered for you and howmuch we pay. In some cases wemight decide a service or drug is not covered or is no longer coveredby Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Making an appealIf we make a coverage decision and you are not satisfied with this decision, you can “appeal” thedecision. An appeal is a formal way of asking us to review and change a coverage decision we havemade.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, wereview the coverage decision wemade to check to see if we were following all of the rules properly.Your appeal is handled by different reviewers than those whomade the original unfavorable decision.When we have completed the review, we give you our decision. Under certain circumstances, whichwe discuss later, you can request an expedited or “fast coverage decision” or fast appeal of a coveragedecision.

If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2Appeal is conducted by an independent organization that is not connected to us. (In some situations,your case will be automatically sent to the independent organization for a Level 2 Appeal. If thishappens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If


you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue throughadditional levels of appeal.

Section 4.2 How to get help when you are asking for a coverage decision ormaking an appeal

Would you like some help? Here are resources you may wish to use if you decide to ask for anykind of coverage decision or appeal a decision:

1 You can call us at Customer Service (phone numbers are printed on the back cover of thisbooklet).

1 To get free help from an independent organization that is not connected with our plan,contact your State Health Insurance Assistance Program (see Section 2 of this chapter).

1 Your doctor can make a request for you.

4 For medical care, your doctor can request a coverage decision or a Level 1 Appeal onyour behalf. If your appeal is denied at Level 1, it will be automatically forwarded toLevel 2. To request any appeal after Level 2, your doctor must be appointed as yourrepresentative.

4 For Part D prescription drugs, your doctor or other prescriber can request a coveragedecision or a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level2, your doctor or other prescriber must be appointed as your representative.

1 You can ask someone to act on your behalf. If you want to, you can name another personto act for you as your “representative” to ask for a coverage decision or make an appeal.

4 There may be someone who is already legally authorized to act as your representativeunder State law.

4 If you want a friend, relative, your doctor or other provider, or other person to be yourrepresentative, call Customer Service (phone numbers are printed on the back cover ofthis booklet) and ask for the “Appointment of Representative” form. (The form is alsoavailable on Medicare’s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf or on our website at healthplan.memorialhermann.org/medicare.) The formgives that person permission to act on your behalf. It must be signed by you and by theperson who you would like to act on your behalf. You must give us a copy of the signedform.

1 You also have the right to hire a lawyer to act for you. You may contact your own lawyer,or get the name of a lawyer from your local bar association or other referral service. Thereare also groups that will give you free legal services if you qualify. However, you are notrequired to hire a lawyer to ask for any kind of coverage decision or appeal a decision.


Section 4.3 Which section of this chapter gives the details for your situation?

There are four different types of situations that involve coverage decisions and appeals. Since eachsituation has different rules and deadlines, we give the details for each one in a separate section:

1 Section 5 of this chapter: “Your medical care: How to ask for a coverage decision or makean appeal”

1 Section 6 of this chapter: “Your Part D prescription drugs: How to ask for a coverage decisionor make an appeal”

1 Section 7 of this chapter: “How to ask us to cover a longer inpatient hospital stay if you thinkthe doctor is discharging you too soon”

1 Section 8 of this chapter: “How to ask us to keep covering certain medical services if youthink your coverage is ending too soon” (Applies to these services only: home health care,skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF)services)

If you’re not sure which section you should be using, please call Customer Service (phone numbersare printed on the back cover of this booklet). You can also get help or information from governmentorganizations such as your State Health Insurance Assistance Program (Chapter 2, Section 3, ofthis booklet has the phone numbers for this program).

SECTION 5 Your medical care: How to ask for a coverage decision ormake an appeal

Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisionsand appeals)? If not, you may want to read it before you start this section.

Section 5.1 This section tells what to do if you have problems getting coveragefor medical care or if you want us to pay you back for our share ofthe cost of your care

This section is about your benefits for medical care and services. These benefits are described inChapter 4 of this booklet:Medical Benefits Chart (what is covered and what you pay). To keepthings simple, we generally refer to “medical care coverage” or “medical care” in the rest of thissection, instead of repeating “medical care or treatment or services” every time.

This section tells what you can do if you are in any of the five following situations:

1. You are not getting certain medical care you want, and you believe that this care is coveredby our plan.

2. Our plan will not approve the medical care your doctor or other medical provider wants togive you, and you believe that this care is covered by the plan.


3. You have received medical care or services that you believe should be covered by the plan,but we have said we will not pay for this care.

4. You have received and paid for medical care or services that you believe should be coveredby the plan, and you want to ask our plan to reimburse you for this care.

5. You are being told that coverage for certain medical care you have been getting that wepreviously approved will be reduced or stopped, and you believe that reducing or stoppingthis care could harm your health.

1 NOTE: If the coverage that will be stopped is for hospital care, home health care,skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility(CORF) services, you need to read a separate section of this chapter because special rulesapply to these types of care. Here’s what to read in those situations:

4 Chapter 9, Section 7: How to ask us to cover a longer inpatient hospital stay if youthink the doctor is discharging you too soon.

4 Chapter 9, Section 8: How to ask us to keep covering certain medical services if youthink your coverage is ending too soon. This section is about three services only: homehealth care, skilled nursing facility care, and Comprehensive Outpatient RehabilitationFacility (CORF) services.

1 For all other situations that involve being told that medical care you have been gettingwill be stopped, use this section (Section 5) as your guide for what to do.

Which of these situations are you in?

This is what you can do:If you are in this situation:

You can ask us to make a coverage decision for you.Do you want to find out whether we willcover the medical care or services you want? Go to the next section of this chapter, Section 5.2.

You canmake an appeal. (This means you are askingus to reconsider.)

Have we already told you that we will notcover or pay for a medical service in the waythat you want it to be covered or paid for? Skip ahead to Section 5.3 of this chapter.

You can send us the bill.Do you want to ask us to pay you back formedical care or services you have alreadyreceived and paid for?

Skip ahead to Section 5.5 of this chapter.


Section 5.2 Step-by-step: How to ask for a coverage decision(how to ask our plan to authorize or provide the medical care coverageyou want)

Legal Terms

When a coverage decision involves your medicalcare, it is called an “organization determination.”

Step 1: You ask our plan to make a coverage decision on the medical care you are requesting.If your health requires a quick response, you should ask us to make a “fast coverage decision.”

Legal Terms

A “fast coverage decision” is called an “expediteddetermination.”

How to request coverage for the medical care you want1 Start by calling, writing, or faxing our plan to make your request for us to authorize orprovide coverage for the medical care you want. You, your doctor, or your representativecan do this.

1 For the details on how to contact us, go to Chapter 2, Section 1 and look for the sectioncalled,How to contact us when you are asking for a coverage decision about your medicalcare.

Generally we use the standard deadlines for giving you our decisionWhen we give you our decision, we will use the “standard” deadlines unless we have agreed touse the “fast” deadlines. A standard coverage decision means we will give you an answerwithin 14 calendar days after we receive your request.

1 However, we can take up to 14 more calendar days if you ask for more time, or if weneed information (such as medical records from out-of-network providers) that may benefityou. If we decide to take extra days to make the decision, we will tell you in writing.

1 If you believe we should not take extra days, you can file a “fast complaint” about ourdecision to take extra days. When you file a fast complaint, we will give you an answerto your complaint within 24 hours. (The process for making a complaint is different fromthe process for coverage decisions and appeals. For more information about the processfor making complaints, including fast complaints, see Section 10 of this chapter.)

If your health requires it, ask us to give you a “fast coverage decision”1 A fast coverage decision means we will answer within 72 hours.


However, we can take up to 14 more calendar days if we find that someinformation that may benefit you is missing (such as medical records fromout-of-network providers), or if you need time to get information to us for thereview. If we decide to take extra days, we will tell you in writing.

4

4 If you believe we should not take extra days, you can file a “fast complaint” aboutour decision to take extra days. (For more information about the process for makingcomplaints, including fast complaints, see Section 10 of this chapter.) We will callyou as soon as we make the decision.

1 To get a fast coverage decision, you must meet two requirements:

4 You can get a fast coverage decision only if you are asking for coverage for medicalcare you have not yet received. (You cannot get a fast coverage decision if yourrequest is about payment for medical care you have already received.)

4 You can get a fast coverage decision only if using the standard deadlines couldcause serious harm to your health or hurt your ability to function.

1 If your doctor tells us that your health requires a “fast coverage decision,” we willautomatically agree to give you a fast coverage decision.

1 If you ask for a fast coverage decision on your own, without your doctor’s support, wewill decide whether your health requires that we give you a fast coverage decision.

4 If we decide that your medical condition does not meet the requirements for a fastcoverage decision, we will send you a letter that says so (and wewill use the standarddeadlines instead).

4 This letter will tell you that if your doctor asks for the fast coverage decision, wewill automatically give a fast coverage decision.

4 The letter will also tell how you can file a “fast complaint” about our decision togive you a standard coverage decision instead of the fast coverage decision yourequested. (For more information about the process for making complaints, includingfast complaints, see Section 10 of this chapter.)

Step 2: We consider your request for medical care coverage and give you our answer.

Deadlines for a “fast” coverage decision1 Generally, for a fast coverage decision, we will give you our answer within 72 hours.

4 As explained above, we can take up to 14 more calendar days under certaincircumstances. If we decide to take extra days to make the coverage decision, wewill tell you in writing.

4 If you believe we should not take extra days, you can file a “fast complaint” aboutour decision to take extra days. When you file a fast complaint, we will give youan answer to your complaint within 24 hours. (For more information about theprocess for making complaints, including fast complaints, see Section 10 of thischapter.


4 If we do not give you our answer within 72 hours (or if there is an extended timeperiod, by the end of that period), you have the right to appeal. Section 5.3 belowtells how to make an appeal.

1 If our answer is yes to part or all of what you requested,we must authorize or providethe medical care coverage we have agreed to provide within 72 hours after we receivedyour request. If we extended the time needed to make our coverage decision, we willauthorize or provide the coverage by the end of that extended period.

1 If our answer is no to part or all of what you requested, we will send you a detailedwritten explanation as to why we said no.

Deadlines for a “standard” coverage decision1 Generally, for a standard coverage decision, we will give you our answer within 14calendar days of receiving your request.

4 We can take up to 14 more calendar days (“an extended time period”) under certaincircumstances. If we decide to take extra days to make the coverage decision, wewill tell you in writing.

4 If you believe we should not take extra days, you can file a “fast complaint” aboutour decision to take extra days. When you file a fast complaint, we will give youan answer to your complaint within 24 hours. (For more information about theprocess for making complaints, including fast complaints, see Section 10 of thischapter.)

4 If we do not give you our answer within 14 calendar days (or if there is an extendedtime period, by the end of that period), you have the right to appeal. Section 5.3below tells how to make an appeal.

1 If our answer is yes to part or all of what you requested,we must authorize or providethe coverage we have agreed to provide within 14 calendar days after we received yourrequest. If we extended the time needed to make our coverage decision, we will authorizeor provide the coverage by the end of that extended period.

1 If our answer is no to part or all of what you requested, we will send you a writtenstatement that explains why we said no.

Step 3: If we say no to your request for coverage for medical care, you decide if you want tomake an appeal.

1 If we say no, you have the right to ask us to reconsider – and perhaps change – this decisionby making an appeal. Making an appeal means making another try to get the medical carecoverage you want.

1 If you decide to make an appeal, it means you are going on to Level 1 of the appealsprocess (see Section 5.3 below).


Section 5.3 Step-by-step: How to make a Level 1 Appeal(how to ask for a review of a medical care coverage decision made byour plan)

Legal Terms

An appeal to the plan about a medical care coveragedecision is called a plan “reconsideration.”

Step 1: You contact us and make your appeal. If your health requires a quick response, you mustask for a “fast appeal.”

What to do

1 To start an appeal, you, your doctor, or your representative, must contact us. For detailson how to reach us for any purpose related to your appeal, go to Chapter 2, Section 1 andlook for section called,How to contact us when you are making an appeal about your medicalcare.

1 If you are asking for a standard appeal, make your standard appeal in writing bysubmitting a request.

4 If you have someone appealing our decision for you other than your doctor, your appealmust include an Appointment of Representative form authorizing this person to representyou. (To get the form, call Customer Service (phone numbers are printed on the backcover of this booklet) and ask for the “Appointment of Representative” form. It is alsoavailable on Medicare’s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf or on our website at healthplan.memorialhermann.org/medicare.) While wecan accept an appeal request without the form, we cannot begin or complete our reviewuntil we receive it. If we do not receive the form within 44 calendar days after receivingyour appeal request (our deadline for making a decision on your appeal), your appealrequest will be dismissed. If this happens, we will send you a written notice explainingyour right to ask the Independent Review Organization to review our decision.

1 If you are asking for a fast appeal, make your appeal in writing or call us at the phonenumber shown in Chapter 2, Section 1 (How to contact us when you are making an appealabout your medical care).

1 Youmust make your appeal request within 60 calendar days from the date on the writtennotice we sent to tell you our answer to your request for a coverage decision. If you miss thisdeadline and have a good reason for missing it, we may give you more time to make yourappeal. Examples of good cause for missing the deadline may include if you had a seriousillness that prevented you from contacting us or if we provided you with incorrect orincomplete information about the deadline for requesting an appeal.

1 You can ask for a copy of the information regarding your medical decision and addmore information to support your appeal.


You have the right to ask us for a copy of the information regarding your appeal. We areallowed to charge a fee for copying and sending this information to you.

4

4 If you wish, you and your doctor may give us additional information to support yourappeal.

If your health requires it, ask for a “fast appeal” (you can make a request by calling us)

Legal Terms

A “fast appeal” is also called an “expeditedreconsideration.”

1 If you are appealing a decision wemade about coverage for care you have not yet received,you and/or your doctor will need to decide if you need a “fast appeal.”

1 The requirements and procedures for getting a “fast appeal” are the same as those forgetting a “fast coverage decision.” To ask for a fast appeal, follow the instructions forasking for a fast coverage decision. (These instructions are given earlier in this section.)

1 If your doctor tells us that your health requires a “fast appeal,” we will give you a fastappeal.

Step 2: We consider your appeal and we give you our answer.

1 When our plan is reviewing your appeal, we take another careful look at all of the informationabout your request for coverage of medical care. We check to see if we were following allthe rules when we said no to your request.

1 We will gather more information if we need it. We may contact you or your doctor to getmore information.

Deadlines for a “fast” appeal1 When we are using the fast deadlines, we must give you our answer within 72 hoursafter we receive your appeal. We will give you our answer sooner if your health requiresus to do so.

4 However, if you ask for more time, or if we need to gather more information thatmay benefit you, we can take up to 14 more calendar days. If we decide to takeextra days to make the decision, we will tell you in writing.

4 If we do not give you an answer within 72 hours (or by the end of the extendedtime period if we took extra days), we are required to automatically send yourrequest on to Level 2 of the appeals process, where it will be reviewed by anindependent organization. Later in this section, we tell you about this organizationand explain what happens at Level 2 of the appeals process.

1 If our answer is yes to part or all of what you requested,we must authorize or providethe coverage we have agreed to provide within 72 hours after we receive your appeal.


1 If our answer is no to part or all of what you requested, we will send you a writtendenial notice informing you that we have automatically sent your appeal to the IndependentReview Organization for a Level 2 Appeal.

Deadlines for a “standard” appeal1 If we are using the standard deadlines, we must give you our answer within 30 calendardays after we receive your appeal if your appeal is about coverage for services you havenot yet received. We will give you our decision sooner if your health condition requiresus to.

4 However, if you ask for more time, or if we need to gather more information thatmay benefit you, we can take up to 14 more calendar days.

4 If you believe we should not take extra days, you can file a “fast complaint” aboutour decision to take extra days. When you file a fast complaint, we will give youan answer to your complaint within 24 hours. (For more information about theprocess for making complaints, including fast complaints, see Section 10 of thischapter.)

4 If we do not give you an answer by the deadline above (or by the end of the extendedtime period if we took extra days), we are required to send your request on to Level2 of the appeals process, where it will be reviewed by an independent outsideorganization. Later in this section, we talk about this review organization and explainwhat happens at Level 2 of the appeals process.

1 If our answer is yes to part or all of what you requested,we must authorize or providethe coverage we have agreed to provide within 30 calendar days after we receive yourappeal.

1 If our answer is no to part or all of what you requested, we will send you a writtendenial notice informing you that we have automatically sent your appeal to the IndependentReview Organization for a Level 2 Appeal.

Step 3: If our plan says no to part or all of your appeal, your case will automatically be senton to the next level of the appeals process.

1 To make sure we were following all the rules when we said no to your appeal, we arerequired to send your appeal to the “Independent Review Organization.”When wedo this, it means that your appeal is going on to the next level of the appeals process,which is Level 2.

Section 5.4 Step-by-step: How a Level 2 Appeal is done

If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level ofthe appeals process. During the Level 2 Appeal, the Independent Review Organization reviewsour decision for your first appeal. This organization decides whether the decision we made shouldbe changed.


Legal Terms

The formal name for the “Independent ReviewOrganization” is the “Independent ReviewEntity.”It is sometimes called the “IRE.”

Step 1: The Independent Review Organization reviews your appeal.

1 The Independent Review Organization is an independent organization that is hiredbyMedicare. This organization is not connected with us and it is not a government agency.This organization is a company chosen by Medicare to handle the job of being theIndependent Review Organization. Medicare oversees its work.

1 We will send the information about your appeal to this organization. This information iscalled your “case file.” You have the right to ask us for a copy of your case file. Weare allowed to charge you a fee for copying and sending this information to you.

1 You have a right to give the Independent Review Organization additional information tosupport your appeal.

1 Reviewers at the Independent Review Organization will take a careful look at all of theinformation related to your appeal.

If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 21 If you had a fast appeal to our plan at Level 1, you will automatically receive a fast appealat Level 2. The review organization must give you an answer to your Level 2 Appealwithin 72 hours of when it receives your appeal.

1 However, if the Independent Review Organization needs to gather more information thatmay benefit you, it can take up to 14 more calendar days.

If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 21 If you had a standard appeal to our plan at Level 1, you will automatically receive astandard appeal at Level 2. The review organization must give you an answer to yourLevel 2 Appeal within 30 calendar days of when it receives your appeal.

1 However, if the Independent Review Organization needs to gather more information thatmay benefit you, it can take up to 14 more calendar days.

Step 2: The Independent Review Organization gives you their answer.

The Independent ReviewOrganization will tell you its decision in writing and explain the reasonsfor it.

1 If the review organization says yes to part or all of what you requested, we mustauthorize the medical care coverage within 72 hours or provide the service within 14calendar days after we receive the decision from the review organization.

1 If this organization says no to part or all of your appeal, it means they agree with usthat your request (or part of your request) for coverage for medical care should not be


approved. (This is called “upholding the decision.” It is also called “turning down yourappeal.”)

4 If the Independent Review Organization “upholds the decision” you have the rightto a Level 3 appeal. However, to make another appeal at Level 3, the dollar valueof the medical care coverage you are requesting must meet a certain minimum. Ifthe dollar value of the coverage you are requesting is too low, you cannot makeanother appeal, which means that the decision at Level 2 is final. The written noticeyou get from the Independent Review Organization will tell you how to find outthe dollar amount to continue the appeals process.

Step 3: If your casemeets the requirements, you choose whether you want to take your appealfurther.

1 There are three additional levels in the appeals process after Level 2 (for a total of fivelevels of appeal).

1 If your Level 2 Appeal is turned down and you meet the requirements to continue withthe appeals process, you must decide whether you want to go on to Level 3 and make athird appeal. The details on how to do this are in the written notice you got after yourLevel 2 Appeal.

1 The Level 3 Appeal is handled by an administrative law judge. Section 9 in this chaptertells more about Levels 3, 4, and 5 of the appeals process.

Section 5.5 What if you are asking us to pay you for our share of a bill you havereceived for medical care?

If you want to ask us for payment for medical care, start by reading Chapter 7 of this booklet: Askingus to pay our share of a bill you have received for covered medical services or drugs. Chapter 7describes the situations in which you may need to ask for reimbursement or to pay a bill you havereceived from a provider. It also tells how to send us the paperwork that asks us for payment.

Asking for reimbursement is asking for a coverage decision from usIf you send us the paperwork that asks for reimbursement, you are asking us to make a coveragedecision (for more information about coverage decisions, see Section 4.1 of this chapter). To makethis coverage decision, we will check to see if the medical care you paid for is a covered service(see Chapter 4:Medical Benefits Chart (what is covered and what you pay)). We will also checkto see if you followed all the rules for using your coverage for medical care (these rules are givenin Chapter 3 of this booklet: Using the plan’s coverage for your medical services).

We will say yes or no to your request1 If the medical care you paid for is covered and you followed all the rules, we will send youthe payment for our share of the cost of your medical care within 60 calendar days after wereceive your request. Or, if you haven’t paid for the services, we will send the paymentdirectly to the provider. When we send the payment, it’s the same as saying yes to yourrequest for a coverage decision.)


1 If the medical care is not covered, or you did not follow all the rules, we will not send payment.Instead, we will send you a letter that says we will not pay for the services and the reasonswhy in detail. (When we turn down your request for payment, it’s the same as saying no toyour request for a coverage decision.)

What if you ask for payment and we say that we will not pay?If you do not agree with our decision to turn you down, you can make an appeal. If you make anappeal, it means you are asking us to change the coverage decision we made when we turned downyour request for payment.

Tomake this appeal, follow the process for appeals that we describe in part 5.3 of this section.Go to this part for step-by-step instructions. When you are following these instructions, please note:

1 If you make an appeal for reimbursement, we must give you our answer within 60 calendardays after we receive your appeal. (If you are asking us to pay you back for medical care youhave already received and paid for yourself, you are not allowed to ask for a fast appeal.)

1 If the Independent Review Organization reverses our decision to deny payment, we mustsend the payment you have requested to you or to the provider within 30 calendar days. Ifthe answer to your appeal is yes at any stage of the appeals process after Level 2, we mustsend the payment you requested to you or to the provider within 60 calendar days.

SECTION 6 Your Part D prescription drugs: How to ask for a coveragedecision or make an appeal

Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisionsand appeals)? If not, you may want to read it before you start this section.

Section 6.1 This section tells you what to do if you have problems getting aPart D drug or you want us to pay you back for a Part D drug

Your benefits as a member of our plan include coverage for many prescription drugs. Please referto our plan’s List of Covered Drugs (Formulary). To be covered, the drug must be used for amedically accepted indication. (A “medically accepted indication” is a use of the drug that is eitherapproved by the Food and Drug Administration or supported by certain reference books. SeeChapter 5, Section 3 for more information about a medically accepted indication.)

1 This section is about your Part D drugs only. To keep things simple, we generally say“drug” in the rest of this section, instead of repeating “covered outpatient prescription drug”or “Part D drug” every time.

1 For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary),rules and restrictions on coverage, and cost information, see Chapter 5 (Using our plan’scoverage for your Part D prescription drugs) and Chapter 6 (What you pay for your Part Dprescription drugs).


Part D coverage decisions and appealsAs discussed in Section 4 of this chapter, a coverage decision is a decision we make about yourbenefits and coverage or about the amount we will pay for your drugs.

Legal Terms

An initial coverage decision about your Part D drugsis called a “coverage determination.”

Here are examples of coverage decisions you ask us to make about your Part D drugs:

1 You ask us to make an exception, including:

4 Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs(Formulary)

4 Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on theamount of the drug you can get)

4 Asking to pay a lower cost-sharing amount for a covered non-preferred drug

1 You ask us whether a drug is covered for you and whether you satisfy any applicable coveragerules. (For example, when your drug is on the plan’s List of Covered Drugs (Formulary) butwe require you to get approval from us before we will cover it for you.)

4 Please note: If your pharmacy tells you that your prescription cannot be filled as written,you will get a written notice explaining how to contact us to ask for a coverage decision.

1 You ask us to pay for a prescription drug you already bought. This is a request for a coveragedecision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.

This section tells you both how to ask for coverage decisions and how to request an appeal. Usethe chart below to help you determine which part has information for your situation:

Which of these situations are you in?


You can ask us to make an exception. (This is a typeof coverage decision.)

Do you need a drug that isn’t on our DrugList or need us to waive a rule or restrictionon a drug we cover? Start with Section 6.2 of this chapter.

You can ask us for a coverage decision.Do you want us to cover a drug on ourDrug List and you believe you meet any Skip ahead to Section 6.4 of this chapter.plan rules or restrictions (such as gettingapproval in advance) for the drug youneed?



You can ask us to pay you back. (This is a type ofcoverage decision.)

Do you want to ask us to pay you back fora drug you have already received and paidfor? Skip ahead to Section 6.4 of this chapter.

You can make an appeal. (This means you are askingus to reconsider.)

Have we already told you that we will notcover or pay for a drug in the way that youwant it to be covered or paid for? Skip ahead to Section 6.5 of this chapter.

Section 6.2 What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an“exception.” An exception is a type of coverage decision. Similar to other types of coveragedecisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medicalreasons why you need the exception approved. We will then consider your request. Here are threeexamples of exceptions that you or your doctor or other prescriber can ask us to make:

1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary). (Wecall it the “Drug List” for short.)

Legal Terms

Asking for coverage of a drug that is not on the DrugList is sometimes called asking for a “formularyexception.”

1 If we agree to make an exception and cover a drug that is not on the Drug List, you will needto pay the cost-sharing amount that applies to drugs in Tier five (5) Specialty. You cannotask for an exception to the copayment or coinsurance amount we require you to pay for thedrug.

2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictionsthat apply to certain drugs on our List of Covered Drugs (Formulary) (for more information, goto Chapter 5 and look for Section 4).

Legal Terms

Asking for removal of a restriction on coverage fora drug is sometimes called asking for a “formularyexception.”


1 The extra rules and restrictions on coverage for certain drugs include:

4 Being required to use the generic version of a drug instead of the brand name drug.

4 Getting plan approval in advance before we will agree to cover the drug for you. (Thisis sometimes called “prior authorization.”)

4 Being required to try a different drug first before we will agree to cover the drug youare asking for. (This is sometimes called “step therapy.”)

4 Quantity limits. For some drugs, there are restrictions on the amount of the drug youcan have.

1 If we agree to make an exception and waive a restriction for you, you can ask for an exceptionto the copayment or coinsurance amount we require you to pay for the drug.

3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our Drug List is inone of five cost-sharing tiers. In general, the lower the cost-sharing tier number, the less youwill pay as your share of the cost of the drug.

Legal Terms

Asking to pay a lower price for a coverednon-preferred drug is sometimes called asking for a“tiering exception.”

1 If your drug is in Tier four (4) you can ask us to cover it at the cost-sharing amount thatapplies to drugs in Tier three (3). This would lower your share of the cost for the drug.

1 If you drug is in Tier two (2), you can ask us to cover it at the cost sharing amount that appliesto drugs in Tier one (1). This would lower your share of the cost for the drug.

1 You cannot ask us to change the cost-sharing tier for any drug in Tier 5.

Section 6.3 Important things to know about asking for exceptions

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a statement that explains the medical reasons forrequesting an exception. For a faster decision, include this medical information from your doctoror other prescriber when you ask for the exception.

Typically, our Drug List includes more than one drug for treating a particular condition. Thesedifferent possibilities are called “alternative” drugs. If an alternative drug would be just as effectiveas the drug you are requesting and would not cause more side effects or other health problems, wewill generally not approve your request for an exception.

We can say yes or no to your request


1 If we approve your request for an exception, our approval usually is valid until the end ofthe plan year. This is true as long as your doctor continues to prescribe the drug for you andthat drug continues to be safe and effective for treating your condition.

1 If we say no to your request for an exception, you can ask for a review of our decision bymaking an appeal. Section 6.5 tells how to make an appeal if we say no.

The next section tells you how to ask for a coverage decision, including an exception.

Section 6.4 Step-by-step: How to ask for a coverage decision, including anexception

Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. Ifyour health requires a quick response, you must ask us to make a “fast coverage decision.” Youcannot ask for a fast coverage decision if you are asking us to pay you back for a drug youalready bought.

What to do1 Request the type of coverage decision you want. Start by calling, writing, or faxing us tomake your request. You, your representative, or your doctor (or other prescriber) can do this.You can also access the coverage decision process through our website. For the details, goto Chapter 2, Section 1 and look for the section called,How to contact us when you are askingfor a coverage decision about your Part D prescription drugs. Or if you are asking us to payyou back for a drug, go to the section called,Where to send a request that asks us to pay forour share of the cost for medical care or a drug you have received.

1 You or your doctor or someone else who is acting on your behalf can ask for a coveragedecision. Section 4 of this chapter tells how you can give written permission to someone elseto act as your representative. You can also have a lawyer act on your behalf.

1 If you want to ask us to pay you back for a drug, start by reading Chapter 7 of this booklet:Asking us to pay our share of a bill you have received for covered medical services or drugs.Chapter 7 describes the situations in which you may need to ask for reimbursement. It alsotells how to send us the paperwork that asks us to pay you back for our share of the cost ofa drug you have paid for.

1 If you are requesting an exception, provide the “supporting statement.” Your doctor orother prescriber must give us the medical reasons for the drug exception you are requesting.(We call this the “supporting statement.”) Your doctor or other prescriber can fax or mailthe statement to us. Or your doctor or other prescriber can tell us on the phone and followup by faxing or mailing a written statement if necessary. See Sections 6.2 and 6.3 for moreinformation about exception requests.

1 We must accept any written request, including a request submitted on the CMS ModelCoverage Determination Request Form, which is available on our website.

If your health requires it, ask us to give you a “fast coverage decision”


Legal Terms

A “fast coverage decision” is called an “expeditedcoverage determination.”

1 When we give you our decision, we will use the “standard” deadlines unless we haveagreed to use the “fast” deadlines. A standard coverage decision means we will give youan answer within 72 hours after we receive your doctor’s statement. A fast coveragedecision means we will answer within 24 hours after we receive your doctor’s statement.

1 To get a fast coverage decision, you must meet two requirements:

4 You can get a fast coverage decision only if you are asking for a drug you have notyet received. (You cannot get a fast coverage decision if you are asking us to payyou back for a drug you have already bought.)

4 You can get a fast coverage decision only if using the standard deadlines couldcause serious harm to your health or hurt your ability to function.

1 If your doctor or other prescriber tells us that your health requires a “fast coveragedecision,” we will automatically agree to give you a fast coverage decision.

1 If you ask for a fast coverage decision on your own (without your doctor’s or otherprescriber’s support), we will decide whether your health requires that we give you a fastcoverage decision.

4 If we decide that your medical condition does not meet the requirements for a fastcoverage decision, we will send you a letter that says so (and wewill use the standarddeadlines instead).

4 This letter will tell you that if your doctor or other prescriber asks for the fastcoverage decision, we will automatically give a fast coverage decision.

4 The letter will also tell how you can file a complaint about our decision to give youa standard coverage decision instead of the fast coverage decision you requested.It tells how to file a “fast” complaint, which means you would get our answer toyour complaint within 24 hours of receiving the complaint. (The process for makinga complaint is different from the process for coverage decisions and appeals. Formore information about the process for making complaints, see Section 10 of thischapter.)

Step 2: We consider your request and we give you our answer.

Deadlines for a “fast” coverage decision1 If we are using the fast deadlines, we must give you our answer within 24 hours.

4 Generally, this means within 24 hours after we receive your request. If you arerequesting an exception, we will give you our answer within 24 hours after wereceive your doctor’s statement supporting your request. We will give you ouranswer sooner if your health requires us to.


4 If we do not meet this deadline, we are required to send your request on to Level 2of the appeals process, where it will be reviewed by an independent outsideorganization. Later in this section, we talk about this review organization and explainwhat happens at Appeal Level 2.

1 If our answer is yes to part or all of what you requested,wemust provide the coveragewe have agreed to provide within 24 hours after we receive your request or doctor’sstatement supporting your request.

1 If our answer is no to part or all of what you requested, we will send you a writtenstatement that explains why we said no. We will also tell you how to appeal.

Deadlines for a “standard” coverage decision about a drug you have not yet received1 If we are using the standard deadlines, we must give you our answer within 72 hours.

4 Generally, this means within 72 hours after we receive your request. If you arerequesting an exception, we will give you our answer within 72 hours after wereceive your doctor’s statement supporting your request. We will give you ouranswer sooner if your health requires us to.

4 If we do not meet this deadline, we are required to send your request on to Level 2of the appeals process, where it will be reviewed by an independent organization.Later in this section, we talk about this review organization and explain what happensat Appeal Level 2.

1 If our answer is yes to part or all of what you requested –

4 If we approve your request for coverage, we must provide the coverage we haveagreed to provide within 72 hours after we receive your request or doctor’sstatement supporting your request.


Deadlines for a “standard” coverage decision about payment for a drug you have alreadybought

1 We must give you our answer within 14 calendar days after we receive your request.

4 If we do not meet this deadline, we are required to send your request on to Level 2of the appeals process, where it will be reviewed by an independent organization.Later in this section, we talk about this review organization and explain what happensat Appeal Level 2.

1 If our answer is yes to part or all of what you requested, we are also required to makepayment to you within 14 calendar days after we receive your request.


Step 3: If we say no to your coverage request, you decide if you want to make an appeal.


1 If we say no, you have the right to request an appeal. Requesting an appeal means askingus to reconsider – and possibly change – the decision we made.

Section 6.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a reviewof a coverage decision made by our plan)

Legal Terms

An appeal to the plan about a Part D drug coveragedecision is called a plan “redetermination.”

Step 1: You contact us and make your Level 1 Appeal. If your health requires a quick response,you must ask for a “fast appeal.”

What to do1 To start your appeal, you (or your representative or your doctor or other prescriber)must contact us.

4 For details on how to reach us by phone, fax, or mail, or on our website, for any purposerelated to your appeal, go to Chapter 2, Section 1, and look for the section called, How tocontact us when you are making an appeal about your Part D prescription drugs.

1 If you are asking for a standard appeal, make your appeal by submitting a writtenrequest.

1 If you are asking for a fast appeal, you may make your appeal in writing or you maycall us at the phone number shown in Chapter 2, Section 1 (How to contact our plan whenyou are making an appeal about your part D prescription drugs).

1 We must accept any written request, including a request submitted on the CMS ModelCoverage Determination Request Form, which is available on our website.

1 You or your doctor or someone else who is acting on your behalf can submit a securedelectronic appeal request available on our website.

1 Youmust make your appeal request within 60 calendar days from the date on the writtennotice we sent to tell you our answer to your request for a coverage decision. If you miss thisdeadline and have a good reason for missing it, we may give you more time to make yourappeal. Examples of good cause for missing the deadline may include if you had a seriousillness that prevented you from contacting us or if we provided you with incorrect orincomplete information about the deadline for requesting an appeal.

1 You can ask for a copy of the information in your appeal and add more information.

4 You have the right to ask us for a copy of the information regarding your appeal. We areallowed to charge a fee for copying and sending this information to you.

4 If you wish, you and your doctor or other prescriber may give us additional informationto support your appeal.


If your health requires it, ask for a “fast appeal”

Legal Terms

A “fast appeal” is also called an “expeditedredetermination.”

1 If you are appealing a decision we made about a drug you have not yet received, you andyour doctor or other prescriber will need to decide if you need a “fast appeal.”

1 The requirements for getting a “fast appeal” are the same as those for getting a “fastcoverage decision” in Section 6.4 of this chapter.

Step 2: We consider your appeal and we give you our answer.

1 When we are reviewing your appeal, we take another careful look at all of the informationabout your coverage request. We check to see if we were following all the rules when wesaid no to your request. Wemay contact you or your doctor or other prescriber to get moreinformation.

Deadlines for a “fast” appeal1 If we are using the fast deadlines, we must give you our answer within 72 hours afterwe receive your appeal. We will give you our answer sooner if your health requires it.

4 If we do not give you an answer within 72 hours, we are required to send yourrequest on to Level 2 of the appeals process, where it will be reviewed by anIndependent Review Organization. Later in this section, we talk about this revieworganization and explain what happens at Level 2 of the appeals process.

1 If our answer is yes to part or all of what you requested,wemust provide the coveragewe have agreed to provide within 72 hours after we receive your appeal.

1 If our answer is no to part or all of what you requested, we will send you a writtenstatement that explains why we said no and how to appeal our decision.

Deadlines for a “standard” appeal1 If we are using the standard deadlines, we must give you our answer within 7 calendardays after we receive your appeal. We will give you our decision sooner if you have notreceived the drug yet and your health condition requires us to do so. If you believe yourhealth requires it, you should ask for “fast” appeal.

4 If we do not give you a decision within 7 calendar days, we are required to sendyour request on to Level 2 of the appeals process, where it will be reviewed by anIndependent Review Organization. Later in this section, we tell about this revieworganization and explain what happens at Level 2 of the appeals process.

1 If our answer is yes to part or all of what you requested –

4 If we approve a request for coverage, we must provide the coverage we haveagreed to provide as quickly as your health requires, but no later than 7 calendardays after we receive your appeal.


4 If we approve a request to pay you back for a drug you already bought, we arerequired to send payment to you within 30 calendar days after we receive yourappeal request.

1 If our answer is no to part or all of what you requested, we will send you a writtenstatement that explains why we said no and how to appeal our decision.

Step 3: If we say no to your appeal, you decide if you want to continue with the appeals processand make another appeal.

1 If we say no to your appeal, you then choose whether to accept this decision or continueby making another appeal.

1 If you decide to make another appeal, it means your appeal is going on to Level 2 of theappeals process (see below).

Section 6.6 Step-by-step: How to make a Level 2 Appeal

If we say no to your appeal, you then choose whether to accept this decision or continue by makinganother appeal. If you decide to go on to a Level 2 Appeal, the Independent ReviewOrganizationreviews the decision we made when we said no to your first appeal. This organization decideswhether the decision we made should be changed.

Legal Terms


Step 1: To make a Level 2 Appeal, you (or your representative or your doctor or otherprescriber) must contact the Independent Review Organization and ask for a review of yourcase.

1 If we say no to your Level 1 Appeal, the written notice we send you will includeinstructions on how to make a Level 2 Appeal with the Independent ReviewOrganization. These instructions will tell who canmake this Level 2 Appeal, what deadlinesyou must follow, and how to reach the review organization.

1 When you make an appeal to the Independent Review Organization, we will send theinformation we have about your appeal to this organization. This information is calledyour “case file.” You have the right to ask us for a copy of your case file. We areallowed to charge you a fee for copying and sending this information to you.

1 You have a right to give the Independent Review Organization additional information tosupport your appeal.

Step 2: The Independent Review Organization does a review of your appeal and gives you ananswer.


1 The Independent Review Organization is an independent organization that is hiredbyMedicare. This organization is not connected with us and it is not a government agency.This organization is a company chosen by Medicare to review our decisions about yourPart D benefits with us.

1 Reviewers at the Independent Review Organization will take a careful look at all of theinformation related to your appeal. The organization will tell you its decision in writingand explain the reasons for it.

Deadlines for “fast” appeal at Level 21 If your health requires it, ask the Independent Review Organization for a “fast appeal.”

1 If the review organization agrees to give you a “fast appeal,” the review organizationmustgive you an answer to your Level 2 Appeal within 72 hours after it receives your appealrequest.

1 If the Independent ReviewOrganization says yes to part or all of what you requested,we must provide the drug coverage that was approved by the review organization within24 hours after we receive the decision from the review organization.

Deadlines for “standard” appeal at Level 21 If you have a standard appeal at Level 2, the review organization must give you an answerto your Level 2 Appeal within 7 calendar days after it receives your appeal.

1 If the Independent ReviewOrganization says yes to part or all of what you requested–

4 If the Independent Review Organization approves a request for coverage, we mustprovide the drug coverage that was approved by the review organization within72 hours after we receive the decision from the review organization.

4 If the Independent Review Organization approves a request to pay you back for adrug you already bought, we are required to send payment to you within 30calendar days after we receive the decision from the review organization.

What if the review organization says no to your appeal?If this organization says no to your appeal, it means the organization agrees with our decision notto approve your request. (This is called “upholding the decision.” It is also called “turning downyour appeal.”)

If the Independent Review Organization “upholds the decision” you have the right to a Level 3appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you arerequestingmust meet a minimum amount. If the dollar value of the drug coverage you are requestingis too low, you cannot make another appeal and the decision at Level 2 is final. The notice you getfrom the Independent Review Organization will tell you the dollar value that must be in dispute tocontinue with the appeals process.

Step 3: If the dollar value of the coverage you are requesting meets the requirement, youchoose whether you want to take your appeal further.


1 There are three additional levels in the appeals process after Level 2 (for a total of fivelevels of appeal).

1 If your Level 2 Appeal is turned down and you meet the requirements to continue withthe appeals process, you must decide whether you want to go on to Level 3 and make athird appeal. If you decide to make a third appeal, the details on how to do this are in thewritten notice you got after your second appeal.

1 The Level 3 Appeal is handled by an administrative law judge. Section 9 in this chaptertells more about Levels 3, 4, and 5 of the appeals process.

SECTION 7 How to ask us to cover a longer inpatient hospital stay ifyou think the doctor is discharging you too soon

When you are admitted to a hospital, you have the right to get all of your covered hospital servicesthat are necessary to diagnose and treat your illness or injury. For more information about ourcoverage for your hospital care, including any limitations on this coverage, see Chapter 4 of thisbooklet:Medical Benefits Chart (what is covered and what you pay).

During your covered hospital stay, your doctor and the hospital staff will be working with you toprepare for the day when you will leave the hospital. They will also help arrange for care you mayneed after you leave.

1 The day you leave the hospital is called your “discharge date.”

1 When your discharge date has been decided, your doctor or the hospital staff will let youknow.

1 If you think you are being asked to leave the hospital too soon, you can ask for a longerhospital stay and your request will be considered. This section tells you how to ask.

Section 7.1 During your inpatient hospital stay, you will get a written noticefrom Medicare that tells about your rights

During your covered hospital stay, you will be given a written notice called An Important Messagefrom Medicare about Your Rights. Everyone with Medicare gets a copy of this notice wheneverthey are admitted to a hospital. Someone at the hospital (for example, a caseworker or nurse) mustgive it to you within two days after you are admitted. If you do not get the notice, ask any hospitalemployee for it. If you need help, please call Customer Service (phone numbers are printed on theback cover of this booklet). You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours aday, 7 days a week. TTY/TDD users should call 1-877-486-2048.

1. Read this notice carefully and ask questions if you don’t understand it. It tells you aboutyour rights as a hospital patient, including:

1 Your right to receive Medicare-covered services during and after your hospital stay, asordered by your doctor. This includes the right to know what these services are, who willpay for them, and where you can get them.


1 Your right to be involved in any decisions about your hospital stay, and know who willpay for it.

1 Where to report any concerns you have about quality of your hospital care.

1 Your right to appeal your discharge decision if you think you are being discharged fromthe hospital too soon.

Legal Terms

The written notice fromMedicare tells you how youcan “request an immediate review.” Requestingan immediate review is a formal, legal way to askfor a delay in your discharge date so that we willcover your hospital care for a longer time.(Section 7.2 below tells you how you can request animmediate review.)

2. You must sign the written notice to show that you received it and understand yourrights.

1 You or someone who is acting on your behalf must sign the notice. (Section 4 of thischapter tells how you can give written permission to someone else to act as yourrepresentative.)

1 Signing the notice shows only that you have received the information about your rights.The notice does not give your discharge date (your doctor or hospital staff will tell youyour discharge date). Signing the notice does notmean you are agreeing on a dischargedate.

3. Keep your copy of the signed notice so you will have the information about making anappeal (or reporting a concern about quality of care) handy if you need it.

1 If you sign the notice more than two days before the day you leave the hospital, you willget another copy before you are scheduled to be discharged.

1 To look at a copy of this notice in advance, you can call Customer Service (phone numbersare printed on the back cover of this booklet) or 1-800 MEDICARE (1-800-633-4227),24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048. You canalso see it online at http://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html


Section 7.2 Step-by-step: How tomake a Level 1 Appeal to change your hospitaldischarge date

If you want to ask for your inpatient hospital services to be covered by us for a longer time, youwill need to use the appeals process to make this request. Before you start, understand what youneed to do and what the deadlines are.

1 Follow the process. Each step in the first two levels of the appeals process is explainedbelow.

1 Meet the deadlines. The deadlines are important. Be sure that you understand and followthe deadlines that apply to things you must do.

1 Ask for help if you need it. If you have questions or need help at any time, please callCustomer Service (phone numbers are printed on the back cover of this booklet). Or call yourState Health Insurance Assistance Program, a government organization that providespersonalized assistance (see Section 2 of this chapter).

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. Itchecks to see if your planned discharge date is medically appropriate for you.

Step 1: Contact the Quality Improvement Organization for your state and ask for a “fastreview” of your hospital discharge. You must act quickly.

What is the Quality Improvement Organization?1 This organization is a group of doctors and other health care professionals who are paidby the Federal government. These experts are not part of our plan. This organization ispaid by Medicare to check on and help improve the quality of care for people withMedicare. This includes reviewing hospital discharge dates for people with Medicare.

How can you contact this organization?1 The written notice you received (An Important Message fromMedicare About Your Rights)tells you how to reach this organization. (Or find the name, address, and phone numberof the Quality Improvement Organization for your state in Chapter 2, Section 4, of thisbooklet.)

Act quickly:1 To make your appeal, you must contact the Quality Improvement Organization beforeyou leave the hospital and no later than your planned discharge date. (Your “planneddischarge date” is the date that has been set for you to leave the hospital.)

4 If you meet this deadline, you are allowed to stay in the hospital after your dischargedate without paying for it while you wait to get the decision on your appeal fromthe Quality Improvement Organization.

4 If you do not meet this deadline, and you decide to stay in the hospital after yourplanned discharge date, you may have to pay all of the costs for hospital care youreceive after your planned discharge date.


1 If you miss the deadline for contacting the Quality Improvement Organization about yourappeal, you can make your appeal directly to our plan instead. For details about this otherway to make your appeal, see Section 7.4.

Ask for a “fast review”:1 Youmust ask the Quality Improvement Organization for a “fast review” of your discharge.Asking for a “fast review” means you are asking for the organization to use the “fast”deadlines for an appeal instead of using the standard deadlines.

Legal Terms

A “fast review” is also called an “immediatereview” or an “expedited review.”

Step 2: TheQuality ImprovementOrganization conducts an independent review of your case.

What happens during this review?1 Health professionals at the Quality Improvement Organization (we will call them “thereviewers” for short) will ask you (or your representative) why you believe coverage forthe services should continue. You don’t have to prepare anything in writing, but you maydo so if you wish.

1 The reviewers will also look at your medical information, talk with your doctor, andreview information that the hospital and we have given to them.

1 By noon of the day after the reviewers informed our plan of your appeal, you will alsoget a written notice that gives your planned discharge date and explains in detail thereasons why your doctor, the hospital, and we think it is right (medically appropriate) foryou to be discharged on that date.

Legal Terms

This written explanation is called the “DetailedNotice of Discharge.” You can get a sample of thisnotice by calling Customer Service (phone numbersare printed on the back cover of this booklet) or1-800-MEDICARE (1-800-633-4227, 24 hours aday, 7 days a week. TTY/TDD users should call1-877-486-2048.) Or you can see a sample noticeonline at http://www.cms.hhs.gov/BNI/

Step 3: Within one full day after it has all the needed information, the Quality ImprovementOrganization will give you its answer to your appeal.

What happens if the answer is yes?1 If the review organization says yes to your appeal,wemust keep providing your coveredinpatient hospital services for as long as these services are medically necessary.


1 You will have to keep paying your share of the costs (such as deductibles or copayments,if these apply). In addition, there may be limitations on your covered hospital services.(See Chapter 4 of this booklet).

What happens if the answer is no?1 If the review organization says no to your appeal, they are saying that your planneddischarge date is medically appropriate. If this happens, our coverage for your inpatienthospital services will end at noon on the day after the Quality Improvement Organizationgives you its answer to your appeal.

1 If the review organization says no to your appeal and you decide to stay in the hospital,then you may have to pay the full cost of hospital care you receive after noon on the dayafter the Quality Improvement Organization gives you its answer to your appeal.

Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make anotherappeal.

1 If the Quality Improvement Organization has turned down your appeal, and you stay inthe hospital after your planned discharge date, then you can make another appeal. Makinganother appeal means you are going on to “Level 2” of the appeals process.

Section 7.3 Step-by-step: How tomake a Level 2 Appeal to change your hospitaldischarge date

If the Quality Improvement Organization has turned down your appeal, and you stay in the hospitalafter your planned discharge date, then you can make a Level 2 Appeal. During a Level 2 Appeal,you ask the Quality Improvement Organization to take another look at the decision they made onyour first appeal. If the Quality Improvement Organization turns down your Level 2 Appeal, youmay have to pay the full cost for your stay after your planned discharge date.

Here are the steps for Level 2 of the appeal process:

Step 1: You contact the Quality Improvement Organization again and ask for another review.

1 You must ask for this review within 60 calendar days after the day the QualityImprovement Organization said no to your Level 1 Appeal. You can ask for this reviewonly if you stayed in the hospital after the date that your coverage for the care ended.

Step 2: The Quality Improvement Organization does a second review of your situation.

1 Reviewers at the Quality Improvement Organization will take another careful look at allof the information related to your appeal.

Step 3: Within 14 calendar days of receipt of your request for a second review, the QualityImprovement Organization reviewers will decide on your appeal and tell you their decision.

If the review organization says yes:


1 We must reimburse you for our share of the costs of hospital care you have receivedsince noon on the day after the date your first appeal was turned down by the QualityImprovement Organization.We must continue providing coverage for your inpatienthospital care for as long as it is medically necessary.

1 You must continue to pay your share of the costs and coverage limitations may apply.

If the review organization says no:1 It means they agree with the decision they made on your Level 1 Appeal and will notchange it.

1 The notice you get will tell you in writing what you can do if you wish to continue withthe review process. It will give you the details about how to go on to the next level ofappeal, which is handled by a judge.

Step 4: If the answer is no, you will need to decide whether you want to take your appealfurther by going on to Level 3.

1 There are three additional levels in the appeals process after Level 2 (for a total of fivelevels of appeal). If the review organization turns down your Level 2 Appeal, you canchoose whether to accept that decision or whether to go on to Level 3 and make anotherappeal. At Level 3, your appeal is reviewed by a judge.

1 Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

Section 7.4 What if you miss the deadline for making your Level 1 Appeal?

You can appeal to us instead

As explained above in Section 7.2, you must act quickly to contact the Quality ImprovementOrganization to start your first appeal of your hospital discharge. (“Quickly” means before youleave the hospital and no later than your planned discharge date.) If you miss the deadline forcontacting this organization, there is another way to make your appeal.

If you use this other way of making your appeal, the first two levels of appeal are different.

Step-by-Step: How to make a Level 1 Alternate Appeal

If you miss the deadline for contacting the Quality Improvement Organization, you can make anappeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines insteadof the standard deadlines.

Legal Terms

A “fast” review (or “fast appeal”) is also called an“expedited appeal”.

Step 1: Contact us and ask for a “fast review.”


1 For details on how to contact us, go to Chapter 2, Section 1 and look for the sectioncalled, How to contact us when you are making an appeal about your medical care.

1 Be sure to ask for a “fast review.” This means you are asking us to give you an answerusing the “fast” deadlines rather than the “standard” deadlines.

Step 2:We do a “fast” review of your planned discharge date, checking to see if it wasmedicallyappropriate.

1 During this review, we take a look at all of the information about your hospital stay. Wecheck to see if your planned discharge date was medically appropriate. We will check tosee if the decision about when you should leave the hospital was fair and followed all therules.

1 In this situation, we will use the “fast” deadlines rather than the standard deadlines forgiving you the answer to this review.

Step 3: We give you our decision within 72 hours after you ask for a “fast review” (“fastappeal”).

1 If we say yes to your fast appeal, it means we have agreed with you that you still needto be in the hospital after the discharge date, and will keep providing your covered inpatienthospital services for as long as it is medically necessary. It also means that we have agreedto reimburse you for our share of the costs of care you have received since the date whenwe said your coverage would end. (You must pay your share of the costs and there maybe coverage limitations that apply.)

1 If we say no to your fast appeal, we are saying that your planned discharge date wasmedically appropriate. Our coverage for your inpatient hospital services ends as of theday we said coverage would end.

4 If you stayed in the hospital after your planned discharge date, then you may haveto pay the full cost of hospital care you received after the planned discharge date.

Step 4: If we say no to your fast appeal, your case will automatically be sent on to the nextlevel of the appeals process.

1 To make sure we were following all the rules when we said no to your fast appeal, weare required to send your appeal to the “Independent Review Organization.”Whenwe do this, it means that you are automatically going on to Level 2 of the appeals process.

Step-by-Step: Level 2 Alternate Appeal Process

If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level ofthe appeals process. During the Level 2 Appeal, an Independent Review Organization reviewsthe decision we made when we said no to your “fast appeal.” This organization decides whetherthe decision we made should be changed.


Legal Terms


Step 1: We will automatically forward your case to the Independent Review Organization.

1 We are required to send the information for your Level 2 Appeal to the IndependentReview Organization within 24 hours of when we tell you that we are saying no to yourfirst appeal. (If you think we are not meeting this deadline or other deadlines, you canmake a complaint. The complaint process is different from the appeal process. Section 10of this chapter tells how to make a complaint.)

Step 2: The Independent Review Organization does a “fast review” of your appeal. Thereviewers give you an answer within 72 hours.

1 The Independent Review Organization is an independent organization that is hiredbyMedicare. This organization is not connected with our plan and it is not a governmentagency. This organization is a company chosen by Medicare to handle the job of beingthe Independent Review Organization. Medicare oversees its work.

1 Reviewers at the Independent Review Organization will take a careful look at all of theinformation related to your appeal of your hospital discharge.

1 If this organization says yes to your appeal, then wemust reimburse you (pay you back)for our share of the costs of hospital care you have received since the date of your planneddischarge. We must also continue the plan’s coverage of your inpatient hospital servicesfor as long as it is medically necessary. You must continue to pay your share of the costs.If there are coverage limitations, these could limit how much we would reimburse or howlong we would continue to cover your services.

1 If this organization says no to your appeal, it means they agree with us that your plannedhospital discharge date was medically appropriate.

4 The notice you get from the Independent Review Organization will tell you inwriting what you can do if you wish to continue with the review process. It willgive you the details about how to go on to a Level 3 Appeal, which is handled bya judge.

Step 3: If the Independent ReviewOrganization turns down your appeal, you choose whetheryou want to take your appeal further.

1 There are three additional levels in the appeals process after Level 2 (for a total of fivelevels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accepttheir decision or go on to Level 3 and make a third appeal.



SECTION 8 How to ask us to keep covering certain medical servicesif you think your coverage is ending too soon

Section 8.1 This section is about three services only:Home health care, skillednursing facility care, and Comprehensive Outpatient RehabilitationFacility (CORF) services

This section is about the following types of care only:

1 Home health care services you are getting.

1 Skilled nursing care you are getting as a patient in a skilled nursing facility. (To learn aboutrequirements for being considered a “skilled nursing facility,” see Chapter 12, Definitionsof important words.)

1 Rehabilitation care you are getting as an outpatient at aMedicare-approved ComprehensiveOutpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment foran illness or accident, or you are recovering from a major operation. (For more informationabout this type of facility, see Chapter 12, Definitions of important words.)

When you are getting any of these types of care, you have the right to keep getting your coveredservices for that type of care for as long as the care is needed to diagnose and treat your illness orinjury. For more information on your covered services, including your share of the cost and anylimitations to coverage that may apply, see Chapter 4 of this booklet:Medical Benefits Chart (whatis covered and what you pay).

When we decide it is time to stop covering any of the three types of care for you, we are requiredto tell you in advance. When your coverage for that care ends, we will stop paying our share of thecost for your care.

If you think we are ending the coverage of your care too soon, you can appeal our decision. Thissection tells you how to ask for an appeal.

Section 8.2 We will tell you in advance when your coverage will be ending

1. You receive a notice in writing. At least two days before our plan is going to stop coveringyour care, you will receive a notice.

1 The written notice tells you the date when we will stop covering the care for you.

1 The written notice also tells what you can do if you want to ask our plan to change thisdecision about when to end your care, and keep covering it for a longer period of time.


Legal Terms

In telling you what you can do, the written notice istelling how you can request a “fast-track appeal.”Requesting a fast-track appeal is a formal, legal wayto request a change to our coverage decision aboutwhen to stop your care. (Section 8.3 below tells howyou can request a fast-track appeal.)

Legal Terms

The written notice is called the “Notice ofMedicareNon-Coverage.” To get a sample copy, callCustomer Service (phone numbers are printed onthe back cover of this booklet) or 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week.(TTY/TDD users should call 1-877-486-2048.) Orsee a copy online at http://www.cms.hhs.gov/BNI/

2. You must sign the written notice to show that you received it.

1 You or someone who is acting on your behalf must sign the notice. (Section 4 tells howyou can give written permission to someone else to act as your representative.)

1 Signing the notice shows only that you have received the information about when yourcoverage will stop. Signing it does not mean you agree with the plan that it’s time tostop getting the care.

Section 8.3 Step-by-step: How to make a Level 1 Appeal to have our plan coveryour care for a longer time

If you want to ask us to cover your care for a longer period of time, you will need to use the appealsprocess to make this request. Before you start, understandwhat you need to do andwhat the deadlinesare.

1 Follow the process. Each step in the first two levels of the appeals process is explainedbelow.

1 Meet the deadlines. The deadlines are important. Be sure that you understand and followthe deadlines that apply to things you must do. There are also deadlines our plan must follow.(If you think we are not meeting our deadlines, you can file a complaint. Section 10 of thischapter tells you how to file a complaint.)


1 Ask for help if you need it. If you have questions or need help at any time, please callCustomer Service (phone numbers are printed on the back cover of this booklet). Or call yourState Health Insurance Assistance Program, a government organization that providespersonalized assistance (see Section 2 of this chapter).

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal anddecides whether to change the decision made by our plan.

Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization for yourstate and ask for a review. You must act quickly.

What is the Quality Improvement Organization?1 This organization is a group of doctors and other health care experts who are paid by theFederal government. These experts are not part of our plan. They check on the quality ofcare received by people with Medicare and review plan decisions about when it’s time tostop covering certain kinds of medical care.

How can you contact this organization?1 The written notice you received tells you how to reach this organization. (Or find thename, address, and phone number of the Quality Improvement Organization for your statein Chapter 2, Section 4, of this booklet.)

What should you ask for?1 Ask this organization for a “fast-track appeal” (to do an independent review) of whetherit is medically appropriate for us to end coverage for your medical services.

Your deadline for contacting this organization.1 You must contact the Quality Improvement Organization to start your appeal no laterthan noon of the day after you receive the written notice telling you when we will stopcovering your care.

1 If you miss the deadline for contacting the Quality Improvement Organization about yourappeal, you can make your appeal directly to us instead. For details about this other wayto make your appeal, see Section 8.5.

Step 2: TheQuality ImprovementOrganization conducts an independent review of your case.

What happens during this review?1 Health professionals at the Quality Improvement Organization (we will call them “thereviewers” for short) will ask you (or your representative) why you believe coverage forthe services should continue. You don’t have to prepare anything in writing, but you maydo so if you wish.

1 The review organization will also look at your medical information, talk with your doctor,and review information that our plan has given to them.

1 By the end of the day the reviewers informed us of your appeal, and you will also get awritten notice from us that explains in detail our reasons for ending our coverage for yourservices.


Legal Terms

This notice explanation is called the “DetailedExplanation of Non-Coverage.”

Step 3: Within one full day after they have all the information they need, the reviewers willtell you their decision.

What happens if the reviewers say yes to your appeal?1 If the reviewers say yes to your appeal, then we must keep providing your coveredservices for as long as it is medically necessary.

1 You will have to keep paying your share of the costs (such as deductibles or copayments,if these apply). In addition, theremay be limitations on your covered services (see Chapter 4of this booklet).

What happens if the reviewers say no to your appeal?1 If the reviewers say no to your appeal, then your coverage will end on the date we havetold you.We will stop paying our share of the costs of this care on the date listed on thenotice.

1 If you decide to keep getting the home health care, or skilled nursing facility care, orComprehensive Outpatient Rehabilitation Facility (CORF) services after this date whenyour coverage ends, then you will have to pay the full cost of this care yourself.

Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make anotherappeal.

1 This first appeal you make is “Level 1” of the appeals process. If reviewers say no to yourLevel 1 Appeal – and you choose to continue getting care after your coverage for the carehas ended – then you can make another appeal.

1 Making another appeal means you are going on to “Level 2” of the appeals process.

Section 8.4 Step-by-step: How to make a Level 2 Appeal to have our plan coveryour care for a longer time

If the Quality Improvement Organization has turned down your appeal and you choose to continuegetting care after your coverage for the care has ended, then you canmake a Level 2 Appeal. Duringa Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decisionthey made on your first appeal. If the Quality Improvement Organization turns down your Level 2Appeal, you may have to pay the full cost for your home health care, or skilled nursing facilitycare, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when wesaid your coverage would end.

Here are the steps for Level 2 of the appeal process:

Step 1: You contact the Quality Improvement Organization again and ask for another review.


1 You must ask for this reviewwithin 60 days after the day when the Quality ImprovementOrganization said no to your Level 1 Appeal. You can ask for this review only if youcontinued getting care after the date that your coverage for the care ended.

Step 2: The Quality Improvement Organization does a second review of your situation.

1 Reviewers at the Quality Improvement Organization will take another careful look at allof the information related to your appeal.

Step 3:Within 14 days of receipt of your appeal request, reviewers will decide on your appealand tell you their decision.

What happens if the review organization says yes to your appeal?1 We must reimburse you for our share of the costs of care you have received since thedate when we said your coverage would end.Wemust continue providing coverage forthe care for as long as it is medically necessary.

1 You must continue to pay your share of the costs and there may be coverage limitationsthat apply.

What happens if the review organization says no?1 It means they agree with the decision wemade to your Level 1 Appeal and will not changeit.

1 The notice you get will tell you in writing what you can do if you wish to continue withthe review process. It will give you the details about how to go on to the next level ofappeal, which is handled by a judge.

Step 4: If the answer is no, you will need to decide whether you want to take your appealfurther.

1 There are three additional levels of appeal after Level 2, for a total of five levels of appeal.If reviewers turn down your Level 2 Appeal, you can choose whether to accept that decisionor to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed bya judge.


Section 8.5 What if you miss the deadline for making your Level 1 Appeal?

You can appeal to us instead

As explained above in Section 8.3, you must act quickly to contact the Quality ImprovementOrganization to start your first appeal (within a day or two, at the most). If you miss the deadlinefor contacting this organization, there is another way to make your appeal. If you use this otherway of making your appeal, the first two levels of appeal are different.

Step-by-Step: How to make a Level 1 Alternate Appeal


If you miss the deadline for contacting the Quality Improvement Organization, you can make anappeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines insteadof the standard deadlines.

Here are the steps for a Level 1 Alternate Appeal:

Legal Terms

A “fast” review (or “fast appeal”) is also called an“expedited appeal”.

Step 1: Contact us and ask for a “fast review.”

1 For details on how to contact us, go to Chapter 2, Section 1 and look for the section called,How to contact us when you are making an appeal about your medical care.

1 Be sure to ask for a “fast review.” This means you are asking us to give you an answerusing the “fast” deadlines rather than the “standard” deadlines.

Step 2: We do a “fast” review of the decision we made about when to end coverage for yourservices.

1 During this review, we take another look at all of the information about your case. Wecheck to see if we were following all the rules when we set the date for ending the plan’scoverage for services you were receiving.

1 We will use the “fast” deadlines rather than the standard deadlines for giving you theanswer to this review.

Step 3: We give you our decision within 72 hours after you ask for a “fast review” (“fastappeal”).

1 If we say yes to your fast appeal, it means we have agreed with you that you need serviceslonger, and will keep providing your covered services for as long as it is medicallynecessary. It also means that we have agreed to reimburse you for our share of the costsof care you have received since the date when we said your coverage would end. (Youmust pay your share of the costs and there may be coverage limitations that apply.)

1 If we say no to your fast appeal, then your coverage will end on the date we told youand we will not pay any share of the costs after this date.

1 If you continued to get home health care, or skilled nursing facility care, or ComprehensiveOutpatient Rehabilitation Facility (CORF) services after the date when we said yourcoverage would end, then you will have to pay the full cost of this care yourself.

Step 4: If we say no to your fast appeal, your case will automatically go on to the next level ofthe appeals process.

1 To make sure we were following all the rules when we said no to your fast appeal, weare required to send your appeal to the “Independent Review Organization.”Whenwe do this, it means that you are automatically going on to Level 2 of the appeals process.


Step-by-Step: Level 2 Alternate Appeal Process

If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level ofthe appeals process. During the Level 2 Appeal, the Independent Review Organization reviewsthe decision we made when we said no to your “fast appeal.” This organization decides whetherthe decision we made should be changed.

Legal Terms


Step 1: We will automatically forward your case to the Independent Review Organization.

1 We are required to send the information for your Level 2 Appeal to the IndependentReview Organization within 24 hours of when we tell you that we are saying no to yourfirst appeal. (If you think we are not meeting this deadline or other deadlines, you canmake a complaint. The complaint process is different from the appeal process. Section 10of this chapter tells how to make a complaint.)

Step 2: The Independent Review Organization does a “fast review” of your appeal. Thereviewers give you an answer within 72 hours.

1 The Independent Review Organization is an independent organization that is hiredbyMedicare. This organization is not connected with our plan and it is not a governmentagency. This organization is a company chosen by Medicare to handle the job of beingthe Independent Review Organization. Medicare oversees its work.

1 Reviewers at the Independent Review Organization will take a careful look at all of theinformation related to your appeal.

1 If this organization says yes to your appeal, then wemust reimburse you (pay you back)for our share of the costs of care you have received since the date when we said yourcoverage would end. We must also continue to cover the care for as long as it is medicallynecessary. You must continue to pay your share of the costs. If there are coveragelimitations, these could limit how much we would reimburse or how long we wouldcontinue to cover your services.

1 If this organization says no to your appeal, it means they agree with the decision ourplan made to your first appeal and will not change it.

4 The notice you get from the Independent Review Organization will tell you inwriting what you can do if you wish to continue with the review process. It willgive you the details about how to go on to a Level 3 Appeal.

Step 3: If the Independent ReviewOrganization turns down your appeal, you choose whetheryou want to take your appeal further.


1 There are three additional levels of appeal after Level 2, for a total of five levels of appeal.If reviewers say no to your Level 2 Appeal, you can choose whether to accept that decisionor whether to go on to Level 3 and make another appeal. At Level 3, your appeal isreviewed by a judge.


SECTION 9 Taking your appeal to Level 3 and beyond

Section 9.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals

This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal,and both of your appeals have been turned down.

If the dollar value of the item or medical service you have appealed meets certain minimum levels,you may be able to go on to additional levels of appeal. If the dollar value is less than the minimumlevel, you cannot appeal any further. If the dollar value is high enough, the written response youreceive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3Appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same way.Here is who handles the review of your appeal at each of these levels.

Level 3 Appeal A judge who works for the Federal government will review your appeal andgive you an answer. This judge is called an “Administrative Law Judge.”

1 If the Administrative Law Judge says yes to your appeal, the appeals process may ormay not be over -Wewill decide whether to appeal this decision to Level 4. Unlike a decisionat Level 2 (Independent ReviewOrganization), we have the right to appeal a Level 3 decisionthat is favorable to you.

4 If we decide not to appeal the decision, we must authorize or provide you with the servicewithin 60 calendar days after receiving the judge’s decision.

4 If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal requestwith any accompanying documents. We may wait for the Level 4 Appeal decision beforeauthorizing or providing the service in dispute.

1 If the Administrative Law Judge says no to your appeal, the appeals process may ormay not be over.

4 If you decide to accept this decision that turns down your appeal, the appeals process isover.

4 If you do not want to accept the decision, you can continue to the next level of the reviewprocess. If the administrative law judge says no to your appeal, the notice you get willtell you what to do next if you choose to continue with your appeal.


Level 4 Appeal The Appeals Council will review your appeal and give you an answer. TheAppeals Council works for the Federal government.

1 If the answer is yes, or if the Appeals Council denies our request to review a favorableLevel 3 Appeal decision, the appeals process may or may not be over - We will decidewhether to appeal this decision to Level 5. Unlike a decision at Level 2 (Independent ReviewOrganization), we have the right to appeal a Level 4 decision that is favorable to you.

4 If we decide not to appeal the decision, we must authorize or provide you with the servicewithin 60 calendar days after receiving the Appeals Council’s decision.

4 If we decide to appeal the decision, we will let you know in writing.

1 If the answer is no or if the Appeals Council denies the review request, the appealsprocess may or may not be over.


4 If you do not want to accept the decision, you might be able to continue to the next levelof the review process. If the Appeals Council says no to your appeal, the notice you getwill tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allowyou to go on, the written notice will also tell you who to contact and what to do next ifyou choose to continue with your appeal.

Level 5 Appeal A judge at the Federal District Court will review your appeal.

1 This is the last step of the administrative appeals process.

Section 9.2 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals

This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal,and both of your appeals have been turned down.

If the value of the drug you have appealed meets a certain dollar amount, you may be able to goon to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. Thewritten response you receive to your Level 2 Appeal will explain who to contact and what to do toask for a Level 3 Appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same way.Here is who handles the review of your appeal at each of these levels.

Level 3 Appeal A judge who works for the Federal government will review your appeal andgive you an answer. This judge is called an Administrative Law Judge.


1 If the answer is yes, the appeals process is over. What you asked for in the appeal has beenapproved. We must authorize or provide the drug coverage that was approved by theAdministrative Law Judge within 72 hours (24 hours for expedited appeals) or makepayment no later than 30 calendar days after we receive the decision.

1 If the answer is no, the appeals process may or may not be over.


4 If you do not want to accept the decision, you can continue to the next level of the reviewprocess. If the administrative law judge says no to your appeal, the notice you get willtell you what to do next if you choose to continue with your appeal.

Level 4 Appeal The Appeals Council will review your appeal and give you an answer. TheAppeals Council works for the Federal government.

1 If the answer is yes, the appeals process is over. What you asked for in the appeal has beenapproved. We must authorize or provide the drug coverage that was approved by theAppeals Council within 72 hours (24 hours for expedited appeals) or make payment nolater than 30 calendar days after we receive the decision.

1 If the answer is no, the appeals process may or may not be over.


4 If you do not want to accept the decision, you might be able to continue to the next levelof the review process. If the Appeals Council says no to your appeal or denies your requestto review the appeal, the notice you get will tell you whether the rules allow you to go onto Level 5 Appeal. If the rules allow you to go on, the written notice will also tell youwho to contact and what to do next if you choose to continue with your appeal.

Level 5 Appeal A judge at the Federal District Court will review your appeal.

1 This is the last step of the appeals process.

MAKING COMPLAINTS

SECTION 10 How to make a complaint about quality of care, waitingtimes, customer service, or other concerns

If your problem is about decisions related to benefits, coverage, or payment, then this section isnot for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section4 of this chapter.


Section 10.1 What kinds of problems are handled by the complaint process?

This section explains how to use the process for making complaints. The complaint process is usedfor certain types of problems only. This includes problems related to quality of care, waiting times,and the customer service you receive. Here are examples of the kinds of problems handled by thecomplaint process.

If you have any of these kinds of problems, you can “make a complaint”

ExampleComplaint

Quality of yourmedical care

1 Are you unhappy with the quality of the care you have received (includingcare in the hospital)?

Respecting yourprivacy

1 Do you believe that someone did not respect your right to privacy orshared information about you that you feel should be confidential?

Disrespect, poorcustomer service, or

1 Has someone been rude or disrespectful to you?

1 Are you unhappy with how our Customer Service has treated you?other negativebehaviors 1 Do you feel you are being encouraged to leave the plan?

Waiting times 1 Are you having trouble getting an appointment, or waiting too long toget it?

1 Have you been kept waiting too long by doctors, pharmacists, or otherhealth professionals? Or by our Customer Service or other staff at theplan?

4 Examples include waiting too long on the phone, in the waiting room,when getting a prescription, or in the exam room.

Cleanliness 1 Are you unhappy with the cleanliness or condition of a clinic, hospital,or doctor’s office?

Information you getfrom us

1 Do you believe we have not given you a notice that we are required togive?

1 Do you think written information we have given you is hard tounderstand?

The process of asking for a coverage decision and making appeals isexplained in sections 4-9 of this chapter. If you are asking for a decision ormaking an appeal, you use that process, not the complaint process.

Timeliness (Thesetypes of complaintsare all related to thetimeliness of our However, if you have already asked us for a coverage decision or made an

appeal, and you think that we are not responding quickly enough, you canalso make a complaint about our slowness. Here are examples:

actions related tocoverage decisionsand appeals)

1 If you have asked us to give you a “fast coverage decision” or a “fastappeal,” and we have said we will not, you can make a complaint.


ExampleComplaint

1 If you believe we are not meeting the deadlines for giving you a coveragedecision or an answer to an appeal you have made, you can make acomplaint.

1 When a coverage decision we made is reviewed and we are told that wemust cover or reimburse you for certain medical services or drugs, thereare deadlines that apply. If you think we are not meeting these deadlines,you can make a complaint.

1 When we do not give you a decision on time, we are required to forwardyour case to the Independent Review Organization. If we do not do thatwithin the required deadline, you can make a complaint.

Section 10.2 The formal name for “making a complaint” is “filing a grievance”

Legal Terms

1 What this section calls a “complaint” is alsocalled a “grievance.”

1 Another term for “making a complaint” is“filing a grievance.”

1 Another way to say “using the process forcomplaints” is “using the process for filinga grievance.”

Section 10.3 Step-by-step: Making a complaint

Step 1: Contact us promptly – either by phone or in writing.

1 Usually, calling Customer Service is the first step. If there is anything else you need todo, Customer Service will let you know. You can reach Customer Service by calling (844)550-6896, 8 a.m. to 8 p.m. seven days a week. TTY/TDD users call 711.

1 If you do not wish to call (or you called and were not satisfied), you can put yourcomplaint in writing and send it to us. If you put your complaint in writing, we will respondto your complaint in writing.


1 Standard Grievances (Complaints)A Standard Grievance is generally resolved within thirty (30) calendar days from the datewe receive your request unless your health or condition requires a quicker response. Ifadditional information is required or you ask for an extension, we may extend the timeframeby up to fourteen (14) calendar days. We will send you a letter notifying you of receipt ofyour complaint. We will research your grievance and may contact you to ask for additionalinformation. Our findings will be communicated to you by mail and/or verbally. If we don’tagree with your grievance in whole or in part, our written decision will explain why we don’tagree with it, and will tell you about any dispute resolution options you may have.

1 Expedited Grievances (Complaints)An Expedited Grievance is responded to within twenty-four (24) hours from the time wereceive your request. You may file an expedited grievance orally or in writing should youdisagree with our decision not to conduct an expedited organization/coverage determinationor an expedited reconsideration/redetermination review. You may also file an expeditedgrievance if you disagree with the Plan’s decision to request a fourteen (14) calendar dayextension to make a decision on an organization/coverage determination or reconsideration.You may file an expedited grievance by contacting Customer Service at (844) 550-6896.

1 Whether you call or write, you should contact Customer Service right away. Thecomplaint must be made within 60 calendar days after you had the problem you want tocomplain about.

1 If you are making a complaint because we denied your request for a “fast coveragedecision” or a “fast appeal,” we will automatically give you a “fast” complaint. If youhave a “fast” complaint, it means we will give you an answer within 24 hours.

Legal Terms

What this section calls a “fast complaint” is alsocalled an “expedited grievance.”

Step 2: We look into your complaint and give you our answer.

1 If possible, we will answer you right away. If you call us with a complaint, we may be ableto give you an answer on the same phone call. If your health condition requires us to answerquickly, we will do that.

1 Most complaints are answered in 30 calendar days. If we need more information and thedelay is in your best interest or if you ask for more time, we can take up to 14 more calendardays (44 calendar days total) to answer your complaint.

1 If we do not agree with some or all of your complaint or don’t take responsibility for theproblem you are complaining about, we will let you know. Our response will include ourreasons for this answer. We must respond whether we agree with the complaint or not.


Section 10.4 You can also make complaints about quality of care to the QualityImprovement Organization

You can make your complaint about the quality of care you received to us by using the step-by-stepprocess outlined above.

When your complaint is about quality of care, you also have two extra options:

1 You can make your complaint to the Quality Improvement Organization. If you prefer,you can make your complaint about the quality of care you received directly to thisorganization (without making the complaint to us).

4 The Quality Improvement Organization is a group of practicing doctors and other healthcare experts paid by the Federal government to check and improve the care given toMedicare patients.

4 To find the name, address, and phone number of the Quality Improvement Organizationfor your state, look in Chapter 2, Section 4, of this booklet. If you make a complaint tothis organization, we will work with them to resolve your complaint.

1 Or you can make your complaint to both at the same time. If you wish, you can makeyour complaint about quality of care to us and also to the Quality Improvement Organization.

Section 10.5 You can also tell Medicare about your complaint

You can submit a complaint about Memorial Hermann Advantage PPO directly to Medicare. Tosubmit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx.Medicare takes your complaints seriously and will use this information to help improve the qualityof the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your issue,please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.


CHAPTER 10Ending your membership

in the plan

Chapter 10. Ending your membership in the plan


Section 1.1 This chapter focuses on ending your membership in our plan ..................... 202

SECTION 2 When can you end your membership in our plan? ........................ 202

Section 2.1 You can end your membership during the Annual Enrollment Period ......... 202

Section 2.2 You can end your membership during the annual Medicare AdvantageDisenrollment Period, but your choices are more limited ............................ 203

Section 2.3 In certain situations, you can end your membership during a SpecialEnrollment Period ......................................................................................... 203

Section 2.4 Where can you get more information about when you can end yourmembership? ................................................................................................. 204

SECTION 3 How do you end your membership in our plan? ............................. 205

Section 3.1 Usually, you end your membership by enrolling in another plan ................. 205

SECTION 4 Until yourmembership ends, youmust keep getting yourmedicalservices and drugs through our plan ............................................... 206

Section 4.1 Until your membership ends, you are still a member of our plan ................ 206

SECTION 5 Memorial Hermann Advantage PPO must end your membershipin the plan in certain situations ........................................................206

Section 5.1 When must we end your membership in the plan? ....................................... 206

Section 5.2 We cannot ask you to leave our plan for any reason related to yourhealth ............................................................................................................ 207

Section 5.3 You have the right to make a complaint if we end your membership in ourplan ............................................................................................................... 208

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 201Chapter 10. Ending your membership in the plan


Section 1.1 This chapter focuses on ending your membership in our plan

Ending your membership in Memorial Hermann Advantage PPO may be voluntary (your ownchoice) or involuntary (not your own choice):

1 You might leave our plan because you have decided that you want to leave.

4 There are only certain times during the year, or certain situations, when youmay voluntarilyend your membership in the plan. Section 2 tells you when you can end your membershipin the plan.

4 The process for voluntarily ending your membership varies depending on what type ofnew coverage you are choosing. Section 3 tells you how to end your membership in eachsituation.

1 There are also limited situations where you do not choose to leave, but we are required toend your membership. Section 5 tells you about situations when we must end yourmembership.

If you are leaving our plan, you must continue to get your medical care and prescription drugsthrough our plan until your membership ends.

SECTION 2 When can you end your membership in our plan?

Youmay end your membership in our plan only during certain times of the year, known as enrollmentperiods. All members have the opportunity to leave the plan during the Annual Enrollment Periodand during the annual Medicare Advantage Disenrollment Period. In certain situations, you mayalso be eligible to leave the plan at other times of the year.

Section 2.1 You can end yourmembership during the Annual Enrollment Period

You can end your membership during theAnnual Enrollment Period (also known as the “AnnualCoordinated Election Period”). This is the time when you should review your health and drugcoverage and make a decision about your coverage for the upcoming year.

1 When is the Annual Enrollment Period? This happens from October 15 to December 7.

1 What type of plan can you switch to during the Annual Enrollment Period? During thistime, you can review your health coverage and your prescription drug coverage. You canchoose to keep your current coverage or make changes to your coverage for the upcomingyear. If you decide to change to a new plan, you can choose any of the following types ofplans:

4 Another Medicare health plan. (You can choose a plan that covers prescription drugsor one that does not cover prescription drugs.)


4 Original Medicare with a separate Medicare prescription drug plan.

4 – or – Original Medicare without a separate Medicare prescription drug plan.

0 If you receive “Extra Help” from Medicare to pay for your prescriptiondrugs: If you switch to Original Medicare and do not enroll in a separateMedicare prescription drug plan, Medicare may enroll you in a drug plan, unlessyou have opted out of automatic enrollment.

Note: If you disenroll from Medicare prescription drug coverage and go withoutcreditable prescription drug coverage, you may need to pay a late enrollment penaltyif you join a Medicare drug plan later. (“Creditable” coverage means the coverage isexpected to pay, on average, at least as much as Medicare’s standard prescription drugcoverage.) See Chapter 6, Section 10 for more information about the late enrollmentpenalty.

1 When will your membership end? Your membership will end when your new plan’scoverage begins on January 1.

Section 2.2 You can end your membership during the annual MedicareAdvantage Disenrollment Period, but your choices aremore limited

You have the opportunity to make one change to your health coverage during the annualMedicareAdvantage Disenrollment Period.

1 When is the annualMedicare Advantage Disenrollment Period?This happens every yearfrom January 1 to February 14.

1 What type of plan can you switch to during the annual Medicare AdvantageDisenrollment Period? During this time, you can cancel your Medicare Advantage Planenrollment and switch to Original Medicare. If you choose to switch to Original Medicareduring this period, you have until February 14 to join a separate Medicare prescription drugplan to add drug coverage.

1 When will your membership end?Your membership will end on the first day of the monthafter we get your request to switch to Original Medicare. If you also choose to enroll in aMedicare prescription drug plan, your membership in the drug plan will begin the first dayof the month after the drug plan gets your enrollment request.

Section 2.3 In certain situations, you can end yourmembership during a SpecialEnrollment Period

In certain situations, members of Memorial Hermann Advantage PPO may be eligible to end theirmembership at other times of the year. This is known as a Special Enrollment Period.

1 Who is eligible for a Special Enrollment Period? If any of the following situations applyto you, you are eligible to end your membership during a Special Enrollment Period. These


are just examples, for the full list you can contact the plan, call Medicare, or visit theMedicarewebsite (http://www.medicare.gov):

4 Usually, when you have moved.

4 If you have Medicaid.

4 If you are eligible for “Extra Help” with paying for your Medicare prescriptions.

4 If we violate our contract with you.

4 If you are getting care in an institution, such as a nursing home or long-term care hospital.

4 If you enroll in the Program of All-inclusive Care for the Elderly (PACE).

1 When are Special Enrollment Periods? The enrollment periods vary depending on yoursituation.

1 What can you do? To find out if you are eligible for a Special Enrollment Period, pleasecall Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users call 1-877-486-2048. If you are eligible to end your membership because of aspecial situation, you can choose to change both your Medicare health coverage andprescription drug coverage. This means you can choose any of the following types of plans:

4 Another Medicare health plan. (You can choose a plan that covers prescription drugs orone that does not cover prescription drugs.)

4 Original Medicare with a separate Medicare prescription drug plan.

4 – or – Original Medicare without a separate Medicare prescription drug plan.

1 If you receive “Extra Help” from Medicare to pay for your prescription drugs:If you switch to OriginalMedicare and do not enroll in a separateMedicare prescriptiondrug plan, Medicare may enroll you in a drug plan, unless you have opted out ofautomatic enrollment.

Note: If you disenroll from Medicare prescription drug coverage and go without creditableprescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicaredrug plan later. (“Creditable” coverage means the coverage is expected to pay, on average, at leastas much as Medicare’s standard prescription drug coverage.) See Chapter 6, Section 10 for moreinformation about the late enrollment penalty.

1 When will your membership end? Your membership will usually end on the first day ofthe month after your request to change your plan is received.

Section 2.4 Where can you get more information about when you can end yourmembership?

If you have any questions or would like more information on when you can end your membership:


1 You can find the information in theMedicare & You 2016 Handbook.


Everyone with Medicare receives a copy of Medicare & You each fall. Those new toMedicare receive it within a month after first signing up.

4

4 You can also download a copy from theMedicare website (http://www.medicare.gov).Or, you can order a printed copy by calling Medicare at the number below.

1 You can contactMedicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 daysa week. TTY/TDD users should call 1-877-486-2048.

SECTION 3 How do you end your membership in our plan?

Section 3.1 Usually, you end your membership by enrolling in another plan

Usually, to end your membership in our plan, you simply enroll in another Medicare plan duringone of the enrollment periods (see Section 2 in this chapter for information about the enrollmentperiods). However, if you want to switch from our plan to Original Medicare without a Medicareprescription drug plan, you must ask to be disenrolled from our plan. There are two ways you canask to be disenrolled:

1 You can make a request in writing to us. Contact Customer Service if you need moreinformation on how to do this (phone numbers are printed on the back cover of this booklet).

1 --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7days a week. TTY/TDD users should call 1-877-486-2048.

Note: If you disenroll from Medicare prescription drug coverage and go without creditableprescription drug coverage, you may need to pay a late enrollment penalty if you join aMedicare drug plan later. (“Creditable” coverage means the coverage is expected to pay, onaverage, at least as much as Medicare’s standard prescription drug coverage.) See Chapter 6,Section 10 for more information about the late enrollment penalty.

The table below explains how you should end your membership in our plan.

This is what you should do:If you would like to switch from ourplan to:

1 Enroll in the new Medicare health plan.1 Another Medicare health plan.

You will automatically be disenrolled fromMemorial Hermann Advantage PPO when yournew plan’s coverage begins.

1 Enroll in the new Medicare prescription drug plan.1 Original Medicare with a separateMedicare prescription drug plan. You will automatically be disenrolled from

Memorial Hermann Advantage PPO when yournew plan’s coverage begins.


This is what you should do:If you would like to switch from ourplan to:

1 Send us a written request to disenroll. ContactCustomer Service if you need more information onhow to do this (phone numbers are printed on theback cover of this booklet).

1 Original Medicare without a separateMedicare prescription drug plan.

4 Note: If you disenroll from aMedicare prescription drug plan andgo without creditable prescriptiondrug coverage, you may need to paya late enrollment penalty if you joina Medicare drug plan later. SeeChapter 6, Section 10 for moreinformation about the lateenrollment penalty.

1 You can also contactMedicare, at1-800-MEDICARE (1-800-633-4227), 24 hours aday, 7 days a week, and ask to be disenrolled. TTY/TTD users should call 1-877-486-2048.

1 You will be disenrolled from Memorial HermannAdvantage PPO when your coverage in OriginalMedicare begins.

SECTION 4 Until your membership ends, you must keep getting yourmedical services and drugs through our plan

Section 4.1 Until your membership ends, you are still a member of our plan

If you leave Memorial Hermann Advantage PPO, it may take time before your membership endsand your new Medicare coverage goes into effect. (See Section 2 for information on when yournew coverage begins.) During this time, you must continue to get your medical care and prescriptiondrugs through our plan.

1 You should continue to use our network pharmacies to get your prescriptions filleduntil yourmembership in our plan ends.Usually, your prescription drugs are only coveredif they are filled at a network pharmacy including through our mail-order pharmacy services.

1 If you are hospitalized on the day that your membership ends, your hospital stay willusually be covered by our plan until you are discharged (even if you are discharged afteryour new health coverage begins).

SECTION 5 Memorial Hermann Advantage PPO must end yourmembership in the plan in certain situations

Section 5.1 When must we end your membership in the plan?

Memorial Hermann Advantage PPO must end your membership in the plan if any of thefollowing happen:


1 If you do not stay continuously enrolled in Medicare Part A and Part B.

1 If you move out of our service area.

1 If you are away from our service area for more than six months.

4 If you move or take a long trip, you need to call Customer Service to find out if the placeyou are moving or traveling to is in our plan’s area. (Phone numbers for Customer Serviceare printed on the back cover of this booklet.)

1 If you become incarcerated (go to prison).

1 If you lie about or withhold information about other insurance you have that providesprescription drug coverage.

1 If you intentionally give us incorrect information when you are enrolling in our plan and thatinformation affects your eligibility for our plan. (We cannot make you leave our plan for thisreason unless we get permission from Medicare first.)

1 If you continuously behave in a way that is disruptive and makes it difficult for us to providemedical care for you and other members of our plan. (We cannot make you leave our planfor this reason unless we get permission from Medicare first.)

1 If you let someone else use your membership card to get medical care. (We cannot make youleave our plan for this reason unless we get permission from Medicare first.)

4 If we end your membership because of this reason, Medicare may have your caseinvestigated by the Inspector General.

1 If you are required to pay the extra Part D amount because of your income and you do notpay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage.

Where can you get more information?

If you have questions or would like more information on when we can end your membership:

1 You can call Customer Service for more information (phone numbers are printed on theback cover of this booklet).

Section 5.2 We cannot ask you to leave our plan for any reason related to yourhealth

Memorial Hermann Advantage PPO is not allowed to ask you to leave our plan for any reasonrelated to your health.

What should you do if this happens?

If you feel that you are being asked to leave our plan because of a health-related reason, you shouldcallMedicare at 1-800-MEDICARE (1-800-633-4227). TTY/TDDusers should call 1-877-486-2048.You may call 24 hours a day, 7 days a week.


Section 5.3 You have the right to make a complaint if we end your membershipin our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending yourmembership. We must also explain how you can make a complaint about our decision to end yourmembership. You can also look in Chapter 9, Section 10 for information about how to make acomplaint.


CHAPTER 11Legal notices

Chapter 11. Legal notices

SECTION 1 Notice about governing law ..............................................................211

SECTION 2 Notice about nondiscrimination .......................................................211

SECTION 3 Notice about Medicare Secondary Payer subrogation rights ....... 211

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 210Chapter 11. Legal notices

SECTION 1 Notice about governing law

Many laws apply to this Evidence of Coverage and some additional provisions may apply becausethey are required by law. This may affect your rights and responsibilities even if the laws are notincluded or explained in this document. The principal law that applies to this document is TitleXVIII of the Social Security Act and the regulations created under the Social Security Act by theCenters for Medicare & Medicaid Services, or CMS. In addition, other Federal laws may applyand, under certain circumstances, the laws of the state you live in.

SECTION 2 Notice about nondiscrimination

We don’t discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed,age, or national origin. All organizations that provide Medicare Advantage Plans, like our plan,must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964,the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with DisabilitiesAct, all other laws that apply to organizations that get Federal funding, and any other laws and rulesthat apply for any other reason.

SECTION 3 Notice aboutMedicare Secondary Payer subrogation rights

We have the right and responsibility to collect for covered Medicare services for which Medicareis not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462,Memorial Hermann Advantage PPO, as aMedicare Advantage Organization, will exercise the samerights of recovery that the Secretary exercises under CMS regulations in subparts B through D ofpart 411 of 42 CFR and the rules established in this section supersede any State laws.

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 211Chapter 11. Legal notices

CHAPTER 12Definitions of important

words

Chapter 12. Definitions of important wordsAmbulatory Surgical Center –AnAmbulatory Surgical Center is an entity that operates exclusivelyfor the purpose of furnishing outpatient surgical services to patients not requiring hospitalizationand whose expected stay in the center does not exceed 24 hours.

Annual Enrollment Period – A set time each fall when members can change their health or drugsplans or switch to Original Medicare. The Annual Enrollment Period is from October 15 untilDecember 7.

Appeal – An appeal is something you do if you disagree with our decision to deny a request forcoverage of health care services or prescription drugs or payment for services or drugs you alreadyreceived. You may also make an appeal if you disagree with our decision to stop services that youare receiving. For example, you may ask for an appeal if we don’t pay for a drug, item, or serviceyou think you should be able to receive. Chapter 9 explains appeals, including the process involvedin making an appeal.

Balance Billing –When a provider (such as a doctor or hospital) bills a patient more than the plan’sallowed cost-sharing amount. As a member of Memorial Hermann Advantage PPO, you only haveto pay our plan’s cost-sharing amounts when you get services covered by our plan. We do not allowproviders to “balance bill” or otherwise charge you more than the amount of cost-sharing your plansays you must pay.

Benefit Period – The way that both our plan and Original Medicare measures your use of hospitaland skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospitalor skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospitalcare (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursingfacility after one benefit period has ended, a new benefit period begins. There is no limit to thenumber of benefit periods.

Brand Name Drug – A prescription drug that is manufactured and sold by the pharmaceuticalcompany that originally researched and developed the drug. Brand name drugs have the sameactive-ingredient formula as the generic version of the drug. However, generic drugs aremanufactured and sold by other drug manufacturers and are generally not available until after thepatent on the brand name drug has expired.

Catastrophic Coverage Stage – The stage in the Part D Drug Benefit where you pay a lowcopayment or coinsurance for your drugs after you or other qualified parties on your behalf havespent $4,850.00 in covered drugs during the covered year.

Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administersMedicare. Chapter 2 explains how to contact CMS.

Coinsurance – An amount you may be required to pay as your share of the cost for services orprescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example,20%).

Combined Maximum Out-of-Pocket Amount – This is the most you will pay in a year for allPart A and Part B services from both network (preferred) providers and out-of-network

2016 Evidence of Coverage for Memorial Hermann Advantage PPO 213Chapter 12. Definitions of important words

(non-preferred) providers. See Chapter 4, Section 1.2, for information about your combinedmaximum out-of-pocket amount.

Complaint - The formal name for “making a complaint” is “filing a grievance.” The complaintprocess is used for certain types of problems only. This includes problems related to quality of care,waiting times, and the customer service you receive. See also “Grievance,” in this list of definitions.

Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly providesrehabilitation services after an illness or injury, and provides a variety of services including physicaltherapy, social or psychological services, respiratory therapy, occupational therapy andspeech-language pathology services, and home environment evaluation services.

Copayment – An amount youmay be required to pay as your share of the cost for a medical serviceor supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is aset amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visitor prescription drug.

Cost-sharing – Cost-sharing refers to amounts that a member has to pay when services or drugsare received. Cost-sharing includes any combination of the following three types of payments: (1)any deductible amount a plan may impose before services or drugs are covered; (2) any fixed“copayment” amount that a plan requires when a specific service or drug is received; or (3) any“coinsurance” amount, a percentage of the total amount paid for a service drug, that a plan requireswhen a specific service drug is received. A “daily cost-sharing rate” may apply when your doctorprescribes less than a full month’s supply of certain drugs for you and you are required to pay acopayment.

Cost-Sharing Tier – Every drug on the list of covered drugs is in one of five (5) cost-sharing tiers.In general, the higher the cost-sharing tier, the higher your cost for the drug.

Coverage Determination – A decision about whether a drug prescribed for you is covered by theplan and the amount, if any, you are required to pay for the prescription. In general, if you bringyour prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered underyour plan, that isn’t a coverage determination. You need to call or write to your plan to ask for aformal decision about the coverage. Coverage determinations are called “coverage decisions” inthis booklet. Chapter 9 explains how to ask us for a coverage decision.

Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.

Covered Services – The general term we use in this EOC to mean all of the health care servicesand supplies that are covered by our plan.

Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from anemployer or union) that is expected to pay, on average, at least as much as Medicare’s standardprescription drug coverage. People who have this kind of coverage when they become eligible forMedicare can generally keep that coverage without paying a penalty, if they decide to enroll inMedicare prescription drug coverage later.

Custodial Care – Custodial care is personal care provided in a nursing home, hospice, or otherfacility setting when you do not need skilled medical care or skilled nursing care. Custodial careis personal care that can be provided by people who don’t have professional skills or training, such


as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed orchair, moving around, and using the bathroom. It may also include the kind of health-related carethat most people do themselves, like using eye drops. Medicare doesn’t pay for custodial care.

Customer Service – A department within our plan responsible for answering your questions aboutyour membership, benefits, grievances, and appeals. See Chapter 2 for information about how tocontact Customer Service.

Daily cost-sharing rate – A “daily cost-sharing rate” may apply when your doctor prescribes lessthan a full month’s supply of certain drugs for you and you are required to pay a copayment. Adaily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Hereis an example: If your copayment for a one-month supply of a drug is $30, and a one-month’ssupply in your plan is 30 days, then your “daily cost-sharing rate” is $1 per day. This means youpay $1 for each day’s supply when you fill your prescription.

Deductible – The amount you must pay for health care or prescriptions before our plan begins topay.

Disenroll or Disenrollment – The process of ending your membership in our plan. Disenrollmentmay be voluntary (your own choice) or involuntary (not your own choice).

Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of fillinga prescription. The dispensing fee covers costs such as the pharmacist’s time to prepare and packagethe prescription.

Durable Medical Equipment – Certain medical equipment that is ordered by your doctor formedical reasons. Examples are walkers, wheelchairs, or hospital beds.

Emergency – A medical emergency is when you, or any other prudent layperson with an averageknowledge of health andmedicine, believe that you havemedical symptoms that require immediatemedical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medicalsymptoms may be an illness, injury, severe pain, or a medical condition that is quickly gettingworse.

Emergency Care – Covered services that are: 1) rendered by a provider qualified to furnishemergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition.

Evidence of Coverage (EOC) and Disclosure Information – This document, along with yourenrollment form and any other attachments, riders, or other optional coverage selected, whichexplains your coverage, what we must do, your rights, and what you have to do as a member ofour plan.

Exception – A type of coverage determination that, if approved, allows you to get a drug that isnot on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug atpreferred lower cost-sharing level (a tiering exception). You may also request an exception if yourplan sponsor requires you to try another drug before receiving the drug you are requesting, or theplan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Extra Help – AMedicare program to help people with limited income and resources payMedicareprescription drug program costs, such as premiums, deductibles, and coinsurance.


Generic Drug – A prescription drug that is approved by the Food and Drug Administration (FDA)as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug worksthe same as a brand name drug and usually costs less.

Grievance - A type of complaint youmake about us or one of our network providers or pharmacies,including a complaint concerning the quality of your care. This type of complaint does not involvecoverage or payment disputes.

Home Health Aide – A home health aide provides services that don’t need the skills of a licensednurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carryingout the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

Hospice - An enrollee who has 6 months or less to live has the right to elect hospice. We, yourplan, must provide you with a list of hospices in your geographic area. If you elect hospice andcontinue to pay premiums you are still a member of our plan. You can still obtain all medicallynecessary services as well as the supplemental benefits we offer. The hospice will provide specialtreatment for your state.

Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospitalfor skilled medical services. Even if you stay in the hospital overnight, you might still be consideredan “outpatient.”

Income Related Monthly Adjustment Amount (IRMAA) – If your income is above a certainlimit, you will pay an income-related monthly adjustment amount in addition to your plan premium.For example, individuals with income greater than $85,000 andmarried couples with income greaterthan $170,000 must pay a higher Medicare Part B (medical insurance) and Medicare prescriptiondrug coverage premium amount. This additional amount is called the income-related monthlyadjustment amount. Less than 5 percent of people with Medicare are affected, so most people willnot pay a higher premium.

Initial Coverage Limit – The maximum limit of coverage under the Initial Coverage Stage.

Initial Coverage Stage – This is the stage before your total drug costs including amounts you havepaid and what your plan has paid on your behalf for the year have reached $3,310.00.

Initial Enrollment Period –When you are first eligible for Medicare, the period of time whenyou can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare whenyou turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before themonth you turn 65, includes the month you turn 65, and ends 3 months after the month you turn65.

In-Network Maximum Out-of-Pocket Amount – The most you will pay for covered Part A andPart B services received from network (preferred) providers. After you have reached this limit, youwill not have to pay anything when you get covered services from network providers for the restof the contract year. However, until you reach your combined out-of-pocket amount, you mustcontinue to pay your share of the costs when you seek care from an out-of-network (non-preferred)provider. See Chapter 4, Section 1.2 for information about your in-network maximum out-of-pocketamount.


Institutional Special Needs Plan (SNP) – A Special Needs Plan that enrolls eligible individualswho continuously reside or are expected to continuously reside for 90 days or longer in a long-termcare (LTC) facility. These LTC facilities may include a skilled nursing facility (SNF); nursingfacility (NF); (SNF/NF); an intermediate care facility for the mentally retarded (ICF/MR); and/oran inpatient psychiatric facility. An institutional Special Needs Plan to serve Medicare residents ofLTC facilities must have a contractual arrangement with (or own and operate) the specific LTCfacility(ies).

Institutional Equivalent Special Needs Plan (SNP) – An institutional Special Needs Plan thatenrolls eligible individuals living in the community but requiring an institutional level of care basedon the State assessment. The assessment must be performed using the same respective State levelof care assessment tool and administered by an entity other than the organization offering the plan.This type of Special Needs Plan may restrict enrollment to individuals that reside in a contractedassisted living facility (ALF) if necessary to ensure uniform delivery of specialized care.

Late Enrollment Penalty –An amount added to your monthly premium forMedicare drug coverageif you go without creditable coverage (coverage that is expected to pay, on average, at least as muchas standard Medicare prescription drug coverage) for a continuous period of 63 days or more. Youpay this higher amount as long as you have a Medicare drug plan. There are some exceptions. Forexample, if you receive “Extra Help” from Medicare to pay your prescription drug plan costs, youwill not pay a late enrollment penalty.

List of Covered Drugs (Formulary or “Drug List”) – A list of prescription drugs covered by theplan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. Thelist includes both brand name and generic drugs.

Low Income Subsidy (LIS) – See “Extra Help.”

Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medicalcosts for some people with low incomes and limited resources. Medicaid programs vary from stateto state, but most health care costs are covered if you qualify for both Medicare and Medicaid. SeeChapter 2, Section 6 for information about how to contact Medicaid in your state.

Medically Accepted Indication – A use of a drug that is either approved by the Food and DrugAdministration or supported by certain reference books. See Chapter 5, Section 3 for moreinformation about a medically accepted indication.

Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis,or treatment of your medical condition and meet accepted standards of medical practice.

Medicare – The Federal health insurance program for people 65 years of age or older, some peopleunder age 65 with certain disabilities, and people with End-Stage Renal Disease (generally thosewith permanent kidney failure who need dialysis or a kidney transplant). People with Medicare canget theirMedicare health coverage throughOriginalMedicare a PACE plan, or aMedicare AdvantagePlan.

Medicare Advantage Disenrollment Period – A set time each year when members in a MedicareAdvantage plan can cancel their plan enrollment and switch to Original Medicare. The MedicareAdvantage Disenrollment Period is from January 1 until February 14, 2016.


Medicare Advantage (MA) Plan – Sometimes calledMedicare Part C. A plan offered by a privatecompany that contracts with Medicare to provide you with all your Medicare Part A and Part Bbenefits. AMedicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan,or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a MedicareAdvantage Plan, Medicare services are covered through the plan, and are not paid for under OriginalMedicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drugcoverage). These plans are calledMedicare Advantage Plans with Prescription Drug Coverage.Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that isoffered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

Medicare CoverageGapDiscount Program – A program that provides discounts onmost coveredPart D brand name drugs to Part D enrollees who have reached the Coverage Gap Stage and whoare not already receiving “Extra Help.” Discounts are based on agreements between the Federalgovernment and certain drug manufacturers. For this reason, most, but not all, brand name drugsare discounted.

Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicarehealth plans, including our plan, must cover all of the services that are covered by Medicare PartA and B.

Medicare Health Plan – A Medicare health plan is offered by a private company that contractswith Medicare to provide Part A and Part B benefits to people with Medicare who enroll in theplan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/PilotPrograms, and Programs of All-inclusive Care for the Elderly (PACE).

Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for outpatientprescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A orPart B.

“Medigap” (Medicare Supplement Insurance) Policy – Medicare supplement insurance sold byprivate insurance companies to fill “gaps” in Original Medicare. Medigap policies only work withOriginal Medicare. (A Medicare Advantage Plan is not a Medigap policy.)

Member (Member of our Plan, or “Plan Member”) – A person with Medicare who is eligibleto get covered services, who has enrolled in our plan and whose enrollment has been confirmed bythe Centers for Medicare & Medicaid Services (CMS).

Network Pharmacy – A network pharmacy is a pharmacy where members of our plan can gettheir prescription drug benefits. We call them “network pharmacies” because they contract withour plan. In most cases, your prescriptions are covered only if they are filled at one of our networkpharmacies.

Network Provider – “Provider” is the general term we use for doctors, other health careprofessionals, hospitals, and other health care facilities that are licensed or certified by Medicareand by the State to provide health care services. We call them “network providers” when theyhave an agreement with our plan to accept our payment as payment in full, and in some cases tocoordinate as well as provide covered services to members of our plan. Our plan pays network


providers based on the agreements it has with the providers or if the providers agree to provide youwith plan-covered services. Network providers may also be referred to as “plan providers.”

Optional Supplemental Benefits – Non-Medicare-covered benefits that can be purchased for anadditional premium and are not included in your package of benefits. If you choose to have optionalsupplemental benefits, you may have to pay an additional premium. You must voluntarily electOptional Supplemental Benefits in order to get them.

Organization Determination – The Medicare Advantage plan has made an organizationdetermination when it makes a decision about whether items or services are covered or how muchyou have to pay for covered items or services. The Medicare Advantage plan’s network provideror facility has also made an organization determination when it provides you with an item or service,or refers you to an out-of-network provider for an item or service. Organization determinations arecalled “coverage decisions” in this booklet. Chapter 9 explains how to ask us for a coverage decision.

Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicareis offered by the government, and not a private health plan such as Medicare Advantage Plans andprescription drug plans. Under OriginalMedicare, Medicare services are covered by paying doctors,hospitals, and other health care providers payment amounts established by Congress. You can seeany doctor, hospital, or other health care provider that accepts Medicare. You must pay thedeductible. Medicare pays its share of the Medicare-approved amount, and you pay your share.Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) andis available everywhere in the United States.

Out-of-Network Pharmacy –A pharmacy that doesn’t have a contract with our plan to coordinateor provide covered drugs to members of our plan. As explained in this Evidence of Coverage, mostdrugs you get from out-of-network pharmacies are not covered by our plan unless certain conditionsapply.

Out-of-Network Provider or Out-of-Network Facility – A provider or facility with which wehave not arranged to coordinate or provide covered services to members of our plan. Out-of-networkproviders are providers that are not employed, owned, or operated by our plan or are not undercontract to deliver covered services to you. Using out-of-network providers or facilities is explainedin this booklet in Chapter 3.

Out-of-Pocket Costs – See the definition for “cost-sharing” above. A member’s cost-sharingrequirement to pay for a portion of services or drugs received is also referred to as the member’s“out-of-pocket” cost requirement.

PACE plan – A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical,social, and long-term care (LTC) services for frail people to help people stay independent and livingin their community (instead of moving to a nursing home) as long as possible, while getting thehigh-quality care they need. People enrolled in PACE plans receive both theirMedicare andMedicaidbenefits through the plan.

Part C – see “Medicare Advantage (MA) Plan.”

Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, wewill refer to the prescription drug benefit program as Part D.)


Part D Drugs – Drugs that can be covered under Part D. We may or may not offer all Part D drugs.(See your formulary for a specific list of covered drugs.) Certain categories of drugs were specificallyexcluded by Congress from being covered as Part D drugs.

Preferred Provider Organization (PPO) Plan – A Preferred Provider Organization plan is aMedicare Advantage Plan that has a network of contracted providers that have agreed to treat planmembers for a specified payment amount. A PPO plan must cover all plan benefits whether theyare received from network or out-of-network providers. Member cost-sharing will generally behigher when plan benefits are received from out-of-network providers. PPO plans have an annuallimit on your out-of-pocket costs for services received from network (preferred) providers and ahigher limit on your total combined out-of-pocket costs for services from both network (preferred)and out-of-network (non-preferred) providers.

Premium – The periodic payment to Medicare, an insurance company, or a health care plan forhealth or prescription drug coverage.

Primary Care Provider (PCP) – Your primary care provider is the doctor or other provider yousee first for most health problems. He or she makes sure you get the care you need to keep youhealthy. He or she also may talk with other doctors and health care providers about your care andrefer you to them. In many Medicare health plans, you must see your primary care provider beforeyou see any other health care provider. See Chapter 3, Section 2.1 for information about PrimaryCare Providers.

Prior Authorization – Approval in advance to get services or certain drugs that may or may notbe on our formulary. In the network portion of a PPO, some in-network medical services are coveredonly if your doctor or other network provider gets “prior authorization” from our plan. In a PPO,you do not need prior authorization to obtain out-of-network services. However, you may want tocheck with the plan before obtaining services from out-of-network providers to confirm that theservice is covered by your plan and what your cost-sharing responsibility is. Covered services thatneed prior authorization are marked in the Benefits Chart in Chapter 4. Some drugs are coveredonly if your doctor or other network provider gets “prior authorization” from us. Covered drugsthat need prior authorization are marked in the formulary.

Prosthetics and Orthotics – These are medical devices ordered by your doctor or other health careprovider. Covered items include, but are not limited to, arm, back and neck braces; artificial limbs;artificial eyes; and devices needed to replace an internal body part or function, including ostomysupplies and enteral and parenteral nutrition therapy.

Quality Improvement Organization (QIO) – A group of practicing doctors and other health careexperts paid by the Federal government to check and improve the care given to Medicare patients.See Chapter 2, Section 4 for information about how to contact the QIO for your state.

Quantity Limits – Amanagement tool that is designed to limit the use of selected drugs for quality,safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescriptionor for a defined period of time.

Rehabilitation Services – These services include physical therapy, speech and language therapy,and occupational therapy.


Service Area – A geographic area where a health plan accepts members if it limits membershipbased on where people live. For plans that limit which doctors and hospitals you may use, it’s alsogenerally the area where you can get routine (non-emergency) services. The plan may disenrollyou if you permanently move out of the plan’s service area.

Skilled Nursing Facility (SNF) Care – Skilled nursing care and rehabilitation services providedon a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility careinclude physical therapy or intravenous injections that can only be given by a registered nurse ordoctor.

Special Enrollment Period – A set time when members can change their health or drugs plans orreturn to OriginalMedicare. Situations in which youmay be eligible for a Special Enrollment Periodinclude: if you move outside the service area, if you are getting “Extra Help” with your prescriptiondrug costs, if you move into a nursing home, or if we violate our contract with you.

Special Needs Plan – A special type of Medicare Advantage Plan that provides more focusedhealth care for specific groups of people, such as those who have both Medicare and Medicaid,who reside in a nursing home, or who have certain chronic medical conditions.

Standard Cost-sharing – Standard cost-sharing is cost-sharing other than preferred cost-sharingoffered at a network pharmacy.

Step Therapy – A utilization tool that requires you to first try another drug to treat your medicalcondition before we will cover the drug your physician may have initially prescribed.

Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people withlimited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not thesame as Social Security benefits.

Urgently Needed Services – Urgently needed services are provided to treat a non-emergency,unforeseen medical illness, injury, or condition that requires immediate medical care. Urgentlyneeded services may be furnished by network providers or by out-of-network providers whennetwork providers are temporarily unavailable or inaccessible.


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Memorial Hermann Advantage PPO Customer ServiceCustomer Service – Contact InformationMethod(844) 550-6896CALLCalls to this number are free. 8 a.m. to 8 p.m. seven days a weekCustomer Service also has free language interpreter services available fornon-English speakers.

711TTY/TDDCalls to this number are free. 8 a.m. to 8 p.m. seven days a week

(713)338-6550FAXMemorial Hermann Advantage PPO7737 Southwest FreewaySuite C-97Houston, TX 77074

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Health Information Counseling and Advocacy Program (HICAP) is a state program that gets money fromthe Federal government to give free local health insurance counseling to people with Medicare.

Contact InformationMethod(800) 252-9240(512) 438-3011

CALL

TTY:711TTY/TDD

701 W. 51st St., Austin, Texas 78751WRITEhttp://www.dads.state.tx.us/WEBSITE

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healthplan.memorialhermann.org/medicare

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